What is sphincter of Oddi dysfunction (SOD)?
The sphincter of Oddi is a muscular valve at the end of the common bile duct, which controls the flow of the bile and pancreatic juice into the duodenum.
Sphincter of Oddi dysfunction (SOD) refers to insufficient relaxation or spasm of the sphincter resulting in a build-up of the bile and/or pancreatic juice and subsequently in recurrent upper right abdominal pain or acute pancreatitis .
SOD can occur in individuals with or without the gallbladder. 90% of the affected individuals are women [11,18,23]. Women between 30 and 50 years are at the highest risk.
You can suspect you have SOD when you have chronic upper abdominal pain in the absence of gallstones or after gallbladder removal and when other more common causes of pain, such as irritable bowel syndrome, peptic ulcer or hepatitis, have been excluded by appropriate investigations.
Causes and Mechanism of SOD
The exact cause of SOD is not known .
Risk factors may include microscopic stones in the bile (microlithiasis) , inflammation of the duodenum , opiate addiction , high progesterone levels (contraceptives, pregnancy) , gallbladder removal surgery  or gastric bypass surgery . In some individuals, SOD may appear as a psychosomatic disorder associated with depression, obsessive compulsive behavior or anxiety, sensitive bowel (visceral hyperalgesia) or irritable bowel syndrome [7,19].
The pain can be triggered by large meals and opiates, such as morphine , and possibly by other narcotics, such as fentanyl , codeine, dilaudid, hydrocodone, meperidine and oxycodone.
There is wide agreement about the existence of SOD type I and II, but not type III [11,15,19]:
- SOD type I consists of upper abdominal pain, dilation of the bile ducts and elevated liver enzymes.
- SOD type 2 involves upper abdominal pain and either dilation of bile ducts alone or elevated liver enzymes alone.
- SOD type 3 involves only upper abdominal pain without the bile duct dilation or elevated liver enzymes.
The term pancreatic SOD refers to SOD associated with pancreatitis.
Papillary stenosis or narrowing of the papilla Vateri (the opening of the common bile and pancreatic duct into the duodenum) is a condition similar to SOD; it is probably caused by recurrent pancreatitis or passage of gallstones .
Symptoms of SOD according to Rome III criteria [7,13,23,24]:
- Chronic, recurrent upper right (or middle) abdominal pain that:
- lasts at least 30 minutes, initially builds up and then remains constant during the attack
- is severe enough to interrupt your daily activities
- may radiate to the middle back or right shoulder blade
- is recurrent but does not appear every day
- is not relieved by changing the body position, bowel movements, gastric acid-lowering drugs (antacids, H2 blockers, proton pump inhibitors) or antispasmodics
- may be triggered by meals, especially fatty meals, and opiates, like morphine
- It is not clear if nausea, bloating, constipation, diarrhea and unintended weight loss are symptoms of SOD or eventual coexisting disorders, such as irritable bowel syndrome.
A doctor can make a diagnosis of SOD by endoscopic retrograde cholangiopancreatography (ERCP), which can reveal a dilatation of the common bile or pancreatic duct or both. Along with ERCP, a doctor can perform manometry (in SOD type II and SOD III), that is measuring the pressure within the common bile duct at the level of the sphincter. When the pressure exceeds 40 mm Hg, a doctor usually suggests a cut of the sphincter [1,2].
Blood tests can reveal elevated liver and pancreatic enzymes and bilirubin .
Abdominal ultrasonography can reveal a dilatation of the common bile duct.
Chart 1. Differential Diagnosis of Gallbladder Dyskinesia
Chart 1. References: [5,7,13]
There seems to be no specific diet for sphincter of Oddi dysfunction that would work for everyone. You can experiment with foods and see if any of them is causing pain. According to anecdotal reports, foods that can trigger symptoms in irritable bowel syndrome may also trigger pain in biliary dyskinesia:
- Fatty, oily and fried foods (red meat, fast food, cheese and possibly other dairy products, chocolate)
- Caffeinated, carbonated and alcoholic beverages
- Sugar (sweets, fruits, sweetened beverages)
- Spicy foods
Note, that having small meals may be more beneficial than sticking to a low-fat diet. A low-FODMAP diet may be beneficial for some individuals. Gluten-free diet can probably help only in individuals with celiac disease.
It can also help if you learn how to cope with stress and maintain regular working, eating and sleeping pattern.
SOD can be treated by endoscopic biliary sphincterotomy (EBS), that is by cutting the sphincter of Oddi. This decreases the pressure within the common bile duct and relieves pain [11,12,14]. A doctor may or may not place a small tube (stent) to keep the bile duct open. The effectiveness of sphincterotomy ranges from 55-95% in biliary SOD type I, 70% in type II, and 8-65% in type III [1,4,15,17]. 75-88% of the individuals with pancreatic SOD may benefit from sphincterotomy [15,17]. Individuals with normal pressure (<40 mm Hg) in the bile duct will much less likely benefit from sphincterotomy .
There is INSUFFICIENT EVIDENCE about the long-term effectiveness of the following therapies in relieving pain in SOD [10,18,19]:
- Antibiotics (erythromycin) 
- Antidepressants (amitriptyline)
- Antispasmodic drugs (hyoscyamine, trimebutine )
- Botulinum toxin injection 
- Calcium channel blockers (nicardipine, nifedipine) 
- Digestive enzymes
- Glucagon [8,9]
- Magnesium supplements
- Nitrates (nitroglycerin) 
- Transcutaneous electrical nerve stimulation (TENS)
NOTE: Narcotics may worsen the pain .
There seems to be NO EVIDENCE of the effectiveness of “liver flush,” herbs and other home remedies in relieving pain in SOD.
Acute pancreatitis can occur as a complication of SOD, endoscopic retrograde cholangiopancreatography (ERCP) sphincterotomy or endoscopic biliary sphincterotomy (EBS) . It causes sudden upper middle or left abdominal pain, nausea and vomiting.
- If you have the diagnosis of “sphincter of Oddi dysfunction (SOD) type I” (pain + dilated common bile duct + elevated liver enzymes), you will much more likely benefit from surgical (endoscopic) treatment than when your bile duct and/or liver enzymes are normal (SOD type II or III).
- When you have the diagnosis “suspected” or “possible SOD,” consider diet (small meal portions, avoiding FODMAPs) and life style changes (exercise, coping with stress) rather than surgery.
- When you have the diagnosis of “SOD stenosis,” or “papillary stenosis,” which means your sphincter of Oddi is physically narrowed, surgery is probably the only effective treatment.
- Check for other causes of right upper abdominal pain after gallbladder removal.
- George J et al, 2009, Gallbladder and biliary dyskinesia PubMed
- Craig A et al, 2001, Still awaiting evidence for sphincterotomy for biliary sphincter of Oddi dysfunction Cochrane
- Tierney S et al, 1999, Progesterone alters biliary flow dynamics PubMed Central
- Tooli J, 2002, Biliary dyskinesia PubMed
- Zakko SF et al, 2016, Functional gallbladder disorder in adults UpToDate
- 2013, Type 1 Sphincter of Oddi Dysfunction due to Chronic Opium Addiction ResearchGate
- Bistritz L et al, Sphincter of Oddi dysfunction: Managing the patient with chronic biliary pain PubMed Central
- Ballal MA et al, 2000, Physiology of the Sphincter of Oddi – the present and the future? – part 1 The Saudi Journal of Gastroenterology
- Biliotti D et al, 1989, Effect of glucagon on sphincter of Oddi motor activity PubMed
- Sphincter of Oddi dysfunction International Foundation for Functional Gastrointestinal Disorders
- Romagnuolo J et al, 2014, Recent Research on Sphincter of Oddi Dysfunction PubMed Central
- Cotton PB et al, 2014, Effect of endoscopic sphincterotomy for suspected sphincter of Oddi dysfunction on pain-related disability following cholecystectomy: the EPISOD randomized clinical trial PubMed
- Baillie J, 2010, Sphincter of Oddi dysfunction PubMed
- Seetharam P et al, 2008, Sphincter of Oddi and its Dysfunction PubMed Central
- McLoughlin MT et al, 2007, Sphincter of Oddi dysfunction and pancreatitis PubMed Central
- McCammon RL et al, 1983, Reversal of fentanyl induced spasm of the sphincter of Oddi PubMed
- Sgouros SN et al, 2006, Systematic review: sphincter of Oddi dysfunction–non-invasive diagnostic methods and long-term outcome after endoscopic sphincterotomy PubMed
- Fogel EL et al, Sphincter of Oddi dysfunction GastroHep
- Wilcox CM et al, 2015, Sphincter of Oddi dysfunction Type III: New studies suggest new approaches are needed PubMed Central
- FAQs about sphincter of Oddi dysfunction John Hopkins Medicine
- Sherman S et al 2001, Sphincter of Oddi Dysfunction: Diagnosis and Treatment Journal of the Pancreas
- Vitton V et al, 2012, Medical treatment for sphincter of Oddi dysfunction: Can it replace endoscopic sphincterotomy? PubMed Central
- FAQs about Sphincter of Oddi Dysfunction John Hopkins Medicine
- Rome II diagnostic criteria for functional gastrointestinal disorders Romecriteria.org
- Sphincter of Oddi dysfunction Cleveland Clinic
Can anyone recommend a support group for SOD? Reading the comments on SOD articles seems much more helpful than the articles themselves. I have been sick and in pain since August 2012 and I just got diagnosed July 2018.
About a year ago my family physician actually changed my file from “pain upper right side/liver” to “fibromyalgia”. Even with my blood work showing my liver enzymes being to high. I found a new doctor as soon as he did.
I have found that diet and stress is a major factor. I have been on a pain blocker (non opioud) for years now but I’m finding many people saying that pain pills of any type can cause the symptoms to worsen. So what do you do or take for the pain? Hot baths, massages and heating pads do not help for me.
SOD for 15 years, what works for me 99 percent of the time is to eat something, my food of choice for this is a nut bar! By the third bite it is working. I know it sounds crazy as its so simple. On the odd occasion this does not work, I use Nitrolingual under tongue, takes about 5 minutes to work which seems like forever when in excruciating pain,dripping with sweat and wanting to die but works in the end. Angernine also works but takes about 10 minutes or so. Opiates definitely cause an attack. Hope this helps someone.
Garlic Tablets for Sphincter of oddi aka SOD comes for some after having their gallbladder removed. I as well did not have any stones, I actually had this disorder which is very hard to diagnose. A HIDA scan found that my gallbladder wasn’t functioning. Biliary dyskinesia can also do this. SOD is pretty much like your gallbladder is still there after the removal. Same pains and attacks after eating, chronic diarehha, and chronic spasms in stomach. One treatment is magnesium which will calm the spasms but too much can cause seizure. The real cause of SOD is from candida overgrowth. Many people do not realize but about 90% of the people who have their gallbladder removed suffer from candida overgrowth and gluten intolerance.
Candida is caused by the gluten and what happens is it overgrows in your stomach and yes can even cause the people with stones gallstones. Many doctors do not focus much on candida overgrowth this is the culprit. The diarehha is also caused by the candida overgrowth.
The best thing to do is avoid all fake sugars. Only drink juices (fresh veggies and fruits) and avoid all gluten.
Also if you can, go paleo(or go paleo a few days till stomach calms). in the process also take 2 garlic tabs after your meals ( I use kyolic aged garlic candida cleanse and digestion tabs). After a few days your digestion will return to normal, the spasms and discomfort will cease, and your stools will be normal and not diarehha.
This pill is the miracle worker for SOD. If you can’t get the tabs dice up some garlic and soak in olive oil and spread it on some gluten free bread or crackers or add tons to some recipe. the tabs are great though because they are odorless. Its so sad to see how many people go thru so much with this disorder and how little doctors have answers for this disorder.
Candida overgrowth will also affect the appendix as well causing you to need that removed too. also take probiotics to heal your leaky gut and to keep the balance in your system well. The garlic tabs are best combined with a low carb/paleo diet for the fastest results. They will also work with regular diet too.
Medical therapy may be considered in the initial treatment plans. This includes a low-fat diet, antispasmodics, non-addictive analgesics, nifedipine and nitroglycerin. Usually the side effects of these drugs limit their usefulness, and none of the drugs are specific to the sphincter of Oddi.
Is this always on the right side..My pain is like this but on the left side..Help me Please. Thank you
I don’t know, but it’s unlikely to be on the left. What’s common on the left is trapped gas, also known as splenic flexure syndrome.
I was an OR nurse for 12 years so I am well versed with anatomy. My pain was also on the “left side”. I went without being diagnosed due to the location of the pain not being where the experts stated it should be . I was already on a gluten fee diet, I don’t take any opioids and did not have any gallstones or kidney stones. Had several scans and ultrasounds all done on the “right side”. Spent 2 years in agony back and forth to the doctor. Then started vomiting with every meal then escalated to even fluids,blood pressure became extremely elevated, sweating , and elevated liver enzymes . Ended up in ER had to have emergency ECRP the next day. My condition was related to chronic inflammation of duodenum. I have celiac disease which was diagnosed 10 years before this nightmare began. No, I should not have had to go through what I went through but I did not stop trying to get help and that may be because I could argue anatomical location of organ structures . I have been pain free since my surgery, but I can now feel when the sphincter is not opening and a minor change in body position opens it. I hope this helps. Good luck with your query.
ERCP is diagnostic, as you know. What surgery did you have? A sphincter cut? If so, which one? I’m getting desperate. Have a 9-year-old diagnosis of IBS, but with a suspicious biliary ejection fraction on HIDA scan. Could be biliary dyskinesia or sphincter of Oddi problem. A superspecialist reviewed the many tests I’d had done at that time, and told me it is IBS. Amitriptylline and Antispasmodic (when pain attacks) does help. But almost a decade later, it’s all getting worse. Have tried generally following FODMAP diet. Terribly restrictive diet. I belive it’s caused me malnutrition and the only kidney stone I’ve ever had. Still have chronic (worse) diarrhea and the pain attacks are much more frequent.
Must get to a major GI center. Probably need endoscopic ultrasound and ERCP. Wondering what helped you.
Cannot go on this way.
Ive just come across this article and thought it might help to say that Opiates, and drugs even remotely associated, will trigger a terribly painful attack for me. Enough to take me to hospital. My doctor was the one who told me to stop taking Panedine.Since I have stopped taking it or any other opiates Ive been ok. I have had my gallbladder removed also,quite some time ago which may have alerted him to the possibility as well. Im very careful now to always check that anything I take has no relationship with opiates
I have had SOD for over 14 years and just recently I have had a severe attack that took me to ER. I have had two spinchterotomies in the past, but I have found my diet is the biggest trigger. Does anyone have any suggestions for vegetables that I can eat? Also I have read juicing
It would help to answer if you can tell some of these diet triggers you are experiencing. A common advice is to avoid large meals. Other triggers may differ from person to person a lot. The pain can be also associated with stress.
Maybe this well help someone cope with SOD. I have had this problem for years now even after receiving the gold standard stent procedure by a renowned physician. What has helped me to stop an attack is the immediate drinking of an iced very cold cola type beverage ( which means I always carry such with me in an insulated cup, and the application of a small battery powered vibrating pillow to my back over the pain area. I have also found that being overly excited(adrenaline dumps), any form of alcohol, and opiate pain pills or cough syrups with codeine will start the symptoms very quickly. I avoid these situations at all costs!
This was very informative. I believe learning how to cope with stress can help prevent this type of pain.
The opiate pain pills and cough syrups will ALWAYS initiate an episode. I avoid them as well. However, it is sometimes difficult to get people in the medical community to understand that hydrocodone must be avoided even after a surgical procedure. I was given hydrocodone after a knee surgery and it caused a severe attack. Knee surgery and a pancreas spasm together were awful. I took great care to explain to my doctor this problem, but evidently he was one of the ones who do not given credibility to the diagnosis of Oddi’s.
How much fat is low fat for your SOD diet? My specialist said 35 grams per day, but I have lost 30 pounds and am dangerously skinny now. If I go over the 35g I feel lousy, but I need to gain weight!! What else can I do besides adding more calories and carbs? I’m up to 2600 calories a day and it’s slow going on gaining weight because of the low fat.
Fatty foods might trigger pain is some individuals with SOD, but not in others; it’s to try and see.
It is possible that large meals rather than fatty meals trigger symptoms. It is possible that certain foods trigger symptoms without any obvious logic. Stress may trigger symptoms. A low-FODMAP diet, which is often recommended for irritable bowel syndrome, may help some individuals with SOD. There may be no need to follow it strictly, but you can go food by food or food group and eliminate one food for 2-3 days and see if it helps.
You can get calories from carbohydrates, proteins and fats. There’s about the same amount of calories in 22 grams of fat as in 50 grams of carbs or proteins.
I have been suffering from this for a year and a half now, fatty foods, stress, alcohol and hormones (ovulation) play a huge role in severity of pain or onset of spasms, nausea, etc.. Just try to watch what I eat although hard at times and antispasmodic when too severe…
I’ve suffered from SOD since 2012. So about 5 years. I’m so glad to have found this page! Not necessarily glad that other people are experiencing my hardship, but more so the realization that I’m not alone. There’s so little that is known about SOD and most doctors are useless when it comes to this diagnosis. The success rate of the procedures that ARE available to “treat” this diagnosis do not spark much confidence either. Should I have a procedure that can exacerbate my symptoms? Or should I keep fighting this illness on my own terms? I ask myself these questions often, but not as often as I used to. The following is a very condensed version of a regimen that has worked for ME. So I’m really not trying to push anything, but I hope it helps someone on their journey.
1. Drink plenty of water (64oz/day)
2. Sleep well (at least 7 hrs/night)
3. Avoid alcohol
4. Avoid refined sugars
5. Avoid fatty foods (can’t stress this enough)
6. Avoid caffeine
7. Hyocamine (helps with sphincter spasms)
8. Pepogest (peppermint oil capsules, helps with bloating, kills bad GI bacteria)
9. Papaya enzyme (helps with digestion)
10. L-glutamine (amino acid supplement, helps heal GI lining)
11. Chamomile/Anise tea also helps and provides immediate pain relief (even sometimes during attacks)
Although that may seem like a lot to keep in mind, consider the alternative….debilitating pain.
Hopefully this helps someone. You are not alone. GOD BLESS!!!!
OH and I forgot a very important thing. Every morning when I wake up, I lay flat on the floor and apply abdominal massage. It relaxes all abdominal muscles, including sphincter of oddi, and also helps moves food through the GI tract to avoid any bloating.
Can you be more specific? how and where do you massage? TIA!
I’ve been diagnosed with type2 recently, after having this pain come and go for about 10 years now since my late 20s. The only thing that has worked for me is several ibuprofens (~1g) which obviously I am not recommending, just stating what has worked for me… I am very curious to try to punch in the back technique Ret is recommending. Ret, where exactly do you punch in the back, just general upper right quadrant area? does the pain go away immediately? thx…
Also — forgot to mention, but usually when I get an attack, it keeps coming back during a 3-4 day period, then clears out and nothing for a while, then returns a few weeks later…
I’ve suffered from SOD for nearly 25 yrs now. Have had sphincterotomy but no stents. The attacks have diminished over the years (am now in my 50’s), but I do have the occasional flare-up (from an overly fatty meal, undercooked fish, too much alcohol, etc) but not too often anymore. I have far less stress today than I did back in my 30’s and 40’s so perhaps that was a huge contributor. Sadly, though, it appears my adult son, age 26, may have inherited this deformity of mine (although he has not been diagnosed, yet). I use hyoscyamine or dicyclomine to calm the spasms when needed but have always found that having someone pound (with their fists) VERY hard on my back (usually the upper quadrant where pain is radiating from) works better than anything else. My son, too, has someone pound his back super hard to find relief when the hyoscyamine does not work well for him. Am wondering if anyone else has found this back-pounding beneficial during an attack– and, also, if anyone has found their offspring to have inherited the same odd disease.
The pain that is relieved by a simple punch at the back may also be prevented by something simple, like avoiding something…
I have this too. For 2 yrs now. Taking 2 heaped teaspoons of ground flax/ linseed helps greatly. I just swallow it with water but you can put it in yoghurt and take. The nights i take it, i dont get the pain the following day. When i miss a dose the pain comes the next day.
I have this for about six years now and getting worse! Can’t sleep at all without sleeping tablets anymore as the links so bad! I’m never ever pain free and slowly losing my mind. Don’t mind if i don’t wake up in the morning…
I hear you, Ekatarina! About 9 years for me, but now getting worse. With trying to mostly folllow the restrictive FODMAP-minimizing diet, IBS-D, and the now more frequent spasmodic abdominal pain in right upper quadrant, my quality of life is crap.
I’ve felt I couldn’t bear waking to yet amother day. But stumbled upon this tonight. Jeez, it’s both good and tragic to find others here who can relate, because they are also suffering. I hope you’ll feel unserstood and supported here. Hope that will help you keep going, and maybe lead you to better medical intervention. Maybe we’ll find some helpful ideas in this forum.
Is there any adverse effect of eating meat?
Fatty meats might trigger more pain than lean meats, but this also depends on the amount eaten. I’m not sure if meat by itself would trigger more pain than other foods.
I think steamed fish is better, as it has less fat.
I’ve been dealing w/ this for 9 yrs. If at home when attack starts, a hot shower with water hitting the so area helps. Also a small bowl of oatmeal first thing in the a.m. may help me prevent an attack. Do not want to use drugs. Wish i could offer more .
Yes, hot water is good, hot bath even better than shower. I’m carrying my hot water bottle everywhere with me. It’s a distraction at least but it really helps to relax that muscle.
I’m so sorry for you Chuck..If you didn’t get help in 9 years, so i have no hope at all. Fill so rotten, can’t get up, sometimes can’t reach for my painkillers, it’s a nightmare , not life.
If you find out something, please let us know. Thank you, take care!
Very sorry, Chuck. Same time frame for me. But now getting worse. Agree with others about warmth soothing. Love my microwaved Bed Buddy. But when the clenching pain flares, I usually have to reach for antispasmodoc (hyoscyamine). Often, that reduces the unbearable pain without other drugs. But I’m really tired of it all. I was thinking I need to get to a major GI disorder center. Was thinking I might have to have ERCP and maybe sphincterotomy. Now I’ve read that some others who’ve had those procedures continue to suffer, or have a relapse.
I really don’t know what to do.
Everyone struggling with whatever this really is, seems slightly different in symptoms, testing and procedures endured, and in outcome. Hope there’ll be advances in diagnosis and better treatments coming.