When fat intolerance becomes Sphincter of Oddi Dysfunction.
Mary has had constipation-predominant IBS for most of her adult life. She also has severe intolerance to fats and more recently a lot of other foods, which give her symptoms of bloating and pain. She tries to control her symptoms by taking a restricted diet, but any lapse makes her panic and brings on the symptoms she most dreads.
Constipation is often associated with gallstones. Stagnation of the colon may be accompanied by stagnation in the gallbladder, facilitating an overgrowth of bacteria which may form a nidus for supersaturated cholesterol in bile to come out of solution form stones and cause inflammation of the gall bladder wall. Cholecystitis is a major cause of fat intolerance, but removal of her gall bladder only made the problem worse. Any ingestion of fat could leave her in agonies of pain and cause her severe bloating. She also developed bloating with fruit and vegetables, perhaps because the constant leakage of bile acid irritated her intestine or because stagnation of the small intestine led to bacterial overgrowth. It was only when her doctors found that the severe pain she experienced with fat was associated with raised liver enzymes that they confirmed the diagnosis of Sphincter of Oddi Dysfunction.
The Sphincter of Oddi is a ring of muscle that lies at the end of the common bile duct that normally relaxes to allow bile and pancreatic secretions to enter the duodenum during digestion of a meal. Between meals, it is normally under a state of tonic contraction but release of the hormone cholecystokinin by fat and protein in a meal relaxes the sphincter, induces peristaltic contractions in the common bile duct and also contracts and gall bladder and stimulates pancreatic secretion.
Sphincter of Oddi dysfunction can occur because of scarring or inflammation but most often results from a functional spasm of Oddi’s sphincter and dysmotility of the terminal few centimetres of the common bile duct. It would seem to bear an uncanny resemblance to the anal spasm and distal colonic dyskinesia recorded in patients with constipation predominant IBS. That would seem to suggest that her SOD may be a component of IBS in some people. SOD is often instigated by cholecystectomy, which impairs the response of the sphincter to cholecystokinin. Nowadays many surgeons treat SOD by dividing the sphincter to aid drainage of bile, but that has yet been tried for Mary.
The cause of SOD is as uncertain as the cause of IBS. There may be some constitutional or genetic susceptibility, but there is also evidence that SOD is associated with high levels of stress and particularly the use of work, humour, sublimation, denial or passive aggression to suppress emotion associated with life trauma. It is more common in middle aged women, whose symptoms initially respond to cholecystectomy but then return often with a vengeance. It may be relevant that constipation is also associated with repression with conscientiousness, denial and depression.
Mary’s symptoms of bloating and extreme fatigue started with a bout of epidemic labyrinthitis, following a prolonged period of multiple stresses. Always conscientious and capable, she never liked to let people down. So she was trying to support her elderly widowed father and also her mother-in-law with dementia, she helping her dyslexic son with his business and she was organising her daughter’s wedding. It had all been a bit too much.
Although Mary denies any trauma in her life, when she was 21, she fled the country to join her boy friend upon discovering she was pregnant. The child was stillborn. Nevertheless, she returned to England, married, had two children and tried to settle down, but the marriage didn’t survive. She was left alone with two small children and a mortgage to support. Never one to give up, Mary put what happened behind her and got on with life with a combination of hard work and humour. She trained to become a teacher.
Mary says her life has always been stressful, though her second husband has been a tower of strength through all her recent woes. They are able to enjoy their retirement with no money worries. Mary describes herself as ‘a happy introvert despite the restrictions imposed by my health problems. I knit and sew when I have the energy and she plans to take up drawing and painting and do more in the garden. As long as I know where I stand and am not flying by the seat of my pants, I can manage.’
Mary has demonstrated a considerable degree of resilience despite the instability of her first marriage. Life could be a lot worse. Her attitude is that ‘we have to play the hand that life deals us as best we can’. Nevertheless, none of us can escape being affected by what has happened to us. This fits with the somewhat stoical psychological profile, described in the study quoted above, and may cause her to react to situations in ways that are no longer relevant, holding onto tension in her gut and repressing the secretion of bile. Excessive biliary secretion leading to bilious vomiting has often had connotations of anger. Bile is a metaphor for anger, and choleric an adjective for angry. I have even read that the Mexican word coraje is used to describe the fury of women who had been so wronged that they vomited bile.
The body always remembers. Such symptoms only make sense when seen from the perspective of what happened. They may be calmed by drugs or procedures that alter the physiology, or by restricting life to avoid the triggers or by denying what happened and toughing it out. But the evidence suggests that long term resolution of persistent post traumatic bodily symptoms is only likely to occur if people can make sense of them and reprocess them with understanding and forgiveness in the context of psychodynamic therapies.
The Sensitive Gut 
Many thanks to Tamily, who responded to this post by Facebook.
This is a condition I have after I had my gall bladder out, I can happily tell you more about the condition and how after three nasty Ercps and now living on a low fat has transformed my life. Some need to think about their diet with this condition as major issue, I get niggles but nothing like it was. The day will come again when my bile duct will become spasmodic and stenosed again bit for now my low fat diet is helping. Happy to help any one with this condition and the advise above is crucial to help manage sphincter of oddi dysfunction.
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Lynne Graves commented on Facebook.
I too have had this since I had my gallbladder out. I was 22 now 51. keeping to very low fat diet does help loads. Although I am naughty but boy do I pay for it!! bad cramps and nearly fainting. Glad to hear your ok at the min x
Tam replied
Yes a low fat diet is paramount, chocolate is the worse thing I can eat for spasms in both my bowel and sphincter of oddi, so I am pretty strict these days. I get niggles all the time but it’s manageable. Other health problems are less manageable unfortunately, but I’d do anything to ensure I get better and in control of my health.
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SOD is not caused by STRESS. Most instances are caused by postcholecystectomy. IBS is a symptom/side effect of SOD not a cause. I’ve had it for 31 years and counting.
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I had my gallbladder out two years ago. I’m just recovering from gastritis, well that’s what the hospital said after being in A and E for eight hours crying in agony. My liver function isn’t working properly and I’m now waiting for an ultrasound. It may be a blocked bile duct due to gall stone.
The pain is horrendous and I’m eating little and often, sickness has subsided.
It is either a gallstone or it may be sphincter of oddi.
I’ve cut out all fat and red meat and have brought a nutri ninja blender which is great.
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Thank you for your comment Sue. You could well be suffering from Sphincter of Oddi dysfunction. Your pain seems excessive for gastritis. The Ultrasound will reveal the presence of gallstones, but if it is clear, you may need an ERCP (endoscopic retrograde choledocho-pancreatography) to outline the bile and pancreatic ducts, measure the sphincter pressure and if the diagnosis is confirmed, proceed to division of the sphincter muscle.
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I have had IBS for many years and was diagnosed with chronic pancreatis 19 years ago. I have had a very stressful life until I retired from work. My dr. Thinks mr pancreatitis problems are the result of sphincter or Oddi ssyndrome. Wondering if my familial high cholesyerol . Could have caused some of this. I eat low fat diet and use enzymes with meals to help. I currently have my 4th stent in my pancreatic duct this year. I have also had liver stones removed and my gall bladder removed which didn’t help my pancreatitis.. I have a very enlarged pancreatic duct with stricture which has kept reforming every 10 weeks. What else can I do?
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Thank you for your comment, Pat. I wish I could come up with an easy answer. Your family history of high cholesterol will increase the risk of gallstones and your stressful lifestyle will tend to make spasm of the sphincter of Oddi more likely. But now it seems like the dilated pancreatic duct is a reservoir for cholesterol stones while the stents will allow bacteria to accumulate in the pancreatic duct. It’s a tricky problem that requires a pancreatic super-specialist. Would antibiotics help? What about medications to dissolve cholesterol stones? Only somebody who has experience in these areas would be able to advise. I hope you can soon find something that works well and for longer term.
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I had my first experience with SOD in November 2021. It was very painful and landed me in the hospital for 6 days. I had a Sphincterotomy done. I am very disappointed in the lack of support I have had when it comes to diet and preventatives. At time of discharge when I asked the nurse for sugestions she handed me a hospital food menu.
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I suffer from the same – Oddi dysfunction. My dad had it too.
I had gallbladder out 15 years ago. . I recommend looking into taking the supplement ox bile, for people who have had gallbladdders removed… and digestive enzymes. I take digestive enzymes – I started off with Dr. B gallbladder formula. I adjusted after I realized I can tolerate- I take super enzymes now.
Life changing!! I’m not uncomfortable after meals. My ALT and AST are now normal. I only take with fatty meals (including healthy fats – like olive oil). Not trying to sell products – I just think doctors hate advising patients to take supplements. I also lost 20 lbs, but that was weight I slowly put on over 4 years- but I couldn’t lose it no matter how much I exercised. Digestive enzymes help me tolerate meals, and shed the excess weight from not breaking down fats properly.
I spent thousands of dollars trying to figure out why my enzymes elevated- I even had a liver biopsy – but once I started taking digestive enzymes – everything returned to normal.before that I was so uncomfortable- even when I was hungry, and hadn’t eaten yet , I had pain. I have more energy now too. It took about a month after starting the ox bile before I felt a lot better -so give it time.
Doctors don’t always mention after they take out your gallbladder that you may be deficient in bile. Bike is needed to break down fats. It’s like detergent- it breaks down fats.
** I did speak with my hepatologist about taking digestive enzymes – she said yes** seems I solved my own problem 👍🏻
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Thank you for your testimonial regarding ox bile and digestive enzymes. It could help a lot of people.
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