Isolated wirsungodyskinesia – a pancreatologist dream or a real clinical entitity – second look at the results of our Nardi provocation tests

Introduction: Sphincter of Oddi (SO) dysfunction (SOD) is a well described clinical entity. Application of prostigmine-morphine (Nardi) provocation test can be useful in the diagnosis. Wirsungodyskinesia – an isolated dysfunction of the pancreatic duct sphincter – was originally suggested on the basis of Nardi tests. The aim of the present study was to evaluate the clinical characteristics of our pts with Nardi test.

Methods: We investigated 85 pts having functional biliary or pancreatic pain, 68 out of 85 had previous cholecystectomy. On admission, all patients completed our questionnaire on abdominal pain and symptoms. Baseline symptoms by the questionnaire were scored from 0 to 7, non-biliary to typical biliary pain symptoms (BPS). Nardi provocation test was performed in all pts. Twofold elevation (compared to the baseline) of ASAT or serum amylase with evoked pain was judged as positive result.

Results: 38 pts (33/38 cholecystectomized, 87%) had negative Nardi test (control group). Isolated Wirsungodyskinesia (amylase but no ASAT elevation) was detected in 12 pts (0/12 were cholecystectomized). In contrary, 23 pts had isolated biliary dyskinesia (ASAT but no amylase elevation), all of them (23/23) had previous cholecystectomy. Finally, 12 pts had combined Wirsungo- and biliary dyskinesia (both ASAT and amylase elevation), again 12/12 were cholecystectomized. There were significant differences between the average BPSs in these groups: 1.7+1.2, 1.1+0.9 vs. 4.8+0.9 and 4.5+1.1, respectively.

Conclusions: In cholecystectomized pts the Nardi provocation test induced SO spasm may evoke isolated biliary or combined biliary and pancreatic outflow obstruction, and this is associated with more typical biliary symptoms. In contrary, isolated Wirsungodyskinesia was detected only in pts without cholecystectomy, in which the lack of ASAT elevation and biliary pain can be due to pressure equalizing function of the intact GB.