Chapter 12 (page 48)

The Pyloric Sphincteric Cylinder in Health and Disease

Go to chapter: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | 39
Chapter 12 (page 48)

Case Reports

Case 12.1 J.S., male aged 28 years. Having swallowed 3 mouthfuls of barium suspension, a hold-up lasting 41 seconds occurred at the pyloric ring (counting had started as soon as the barium entered the gastric fornix). For the first 20 seconds of this period no gastric motor movements were seen; the distal 3.0 to 4.0 cm of the stomach was expanded without being unduly distended. At 20 seconds two successive, incomplete, “segmental” or “cylindrical” contractions of this region occurred (see Chap. 13), followed by commencing emptying into the duodenum at 41 seconds (Fig 12.2). (By “incomplete” is meant a minor to moderate degree of narrowing of the lumen, i.e. not bisecting the barium column).
Case 12.2 S.A., female aged 28 years. There was a hold-up at the pyloric ring lasting 85 seconds. For the first 30 seconds of this period no gastric contractions were seen. Subsequently two incomplete cylindrical contractions of the distal 3.0 to 4.0 cm occurred, followed by commencing emptying into the duodenum at 85 seconds.
Case 12.3 H.A., male aged 61 years. The hold-up at the pyloric ring lasted 128 seconds. At l8 seconds 2 or 3 incomplete contractions occurred, followed by a long period of inactivity. Eventually a few contractions reappeared, associated with emptying at 128 seconds.

Fig. 12.2 A-D. Patient J.S. Initial hold-up at pyloric ring (A, B). Successive, incomplete contractions of pyloric sphincteric cylinder (arrow). Emptying into duodenum (C, D)

Generally speaking a similar sequence of events was seen in the majority of patients in this group, namely a short hold-up at the pyloric ring, followed by 2 or 3 incomplete (or occasionally maximal) contractions of the pyloric sphincteric cylinder and commencing emptying into the duodenum (Fig. 12.3). The degree of dynamic narrowing of the lumen, as seen radiologically, probably corresponds to the amplitude as measured manometrically. This varied greatly among subjects.

Fig. 12.3. The first of two or three maximal contractions of pyloric sphincteric cylinder (arrows) preceding emptying into duodenum

In a minority of subjects in this group the period of hold-up at the pyloric ring was longer, lasting at least 90 seconds and sometimes as long as 2 to 3 minutes. In these patients the stomach invariably had a long, hanging, fish-hook shape, with a sagging greater curvature, which is evidence of hypotonia (Chap. 19). Tilting the table to an angle of 45 degrees, and turning the patient into the left anterior oblique position (i.e. with the right side down), invariably caused immediate emptying into the duodenum even in the absence of visible motor activity.

The following case is an example:

Case 12.4 S.M., female aged 50 years. In the erect position there was sagging of the greater curvature, which was located low down in the abdomen opposite the 5th lumbar vertebra; the shape of the stomach was compatible with hypotonicity. The first incomplete contraction of the pyloric sphincteric cylinder was seen at 60 seconds, with another occurring at 100 seconds. Up to 230 seconds no emptying had occurred. The table was then tilted to 45 degrees and the patient turned into the left anterior oblique position. Immediate emptying occurred in this position in the absence of visible contractions of the pyloric region, indicating patency of the pyloric aperture.