The overlooked gatekeepers: gallbladder and sphincter of Oddi disorders

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The overlooked gatekeepers: gallbladder and sphincter of Oddi disorders

Author: Dr. Bahir Hadi, Consultant Surgeon, PhD · Date: June 2026

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Abstract

If you suffer from severe biliary pain - sharp, intense aching in the upper right abdomen radiating to the back - your doctor will usually check for gallstones first. But what happens when the ultrasound comes back completely clear, yet the agonising pain keeps returning after fatty meals? You may be dealing with the fifth category of Rome V disorders: Gallbladder and Sphincter of Oddi Disorders [1, 2].

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The traffic light of digestion

Your gallbladder stores bile, a fluid that helps digest fat. When you eat, the gallbladder squeezes bile down the common bile duct. At the end of that tube sits a tiny muscular valve called the sphincter of Oddi - a traffic light that opens to let bile (and pancreatic enzymes) into the small intestine and closes when digestion is done [2].

When the gut-brain axis miscommunicates with these structures, the muscular coordination fails [1, 2].

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The diagnostic breakdown

• Functional gallbladder disorder: the gallbladder fails to contract properly to eject bile, causing bile backup and painful pressure - despite the absence of stones or sludge on ultrasound [2].
• Functional biliary / pancreatic sphincter of Oddi dysfunction: the muscular valve gets "stuck" in a closed or spasmed position. This blocks the normal flow of bile or pancreatic enzymes; fluid pressure backs up into the liver or pancreas, resulting in severe pain episodes and sometimes elevated liver or pancreatic enzymes on blood tests [2].

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A cautious modern approach

Historically, surgeons were quick to remove the gallbladder or cut the sphincter of Oddi to relieve this pain. Modern medical consensus now emphasises a conservative approach [1, 2]: because these are fundamentally neuromuscular gut-brain coordination issues, smooth-muscle relaxants, neuromodulators and behavioural therapies are often prioritised over surgery to prevent permanent post-surgical complications [2].

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Work-up at Kirurgen.dk

When biliary disease is suspected, we refer for appropriate ultrasound and blood work. Differential gastrointestinal causes are assessed with gastroscopy and colonoscopy. Continue the DGBI series: Centrally mediated pain, Anorectal DGBIs, Rome V new diagnoses.

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References

1. Rome Foundation. Rome V Diagnostic Criteria for Disorders of Gut-Brain Interaction. Drossman DA, Tack J, Chang L et al. (eds.), 2026 update.
2. Cotton PB, Elta GH, Carter CR, Pasricha PJ, Corazziari ES. Gallbladder and Sphincter of Oddi Disorders. Rome IV/V chapter. Gastroenterology - consensus article.