The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 13 (page 52)

Results in Duodenum

In the second and third parts of the duodenum the base line again represented intraluminal pressure in the absence of radiologically visible motor activity. Two waves of pressure increase were noted manometrically:

  1. Nonrhythmic, simple, brief monophasic waves, causing intraluminal pressure increases of 4.0 to 35 mm Hg (the majority being in the 7.0 to 34 mm Hg range), and lasting 2 to 8 seconds (Fig. 13.2). These waves occurred repeatedly in all subjects and conform to Type I duodenal waves (Foulk et al. l954; Vantrappen et al. l965; Friedman et al l965); it was suggested that they should be designated phasic waves (Texter l968).

  2. In two of the subjects nonrhythmic, complex waves consisting of a rise in base line pressure of 3.0 to 4.0 mm Hg and lasting from 40 seconds to 2½ minutes, with superadded peaks of l9 to 23 mm Hg lasting for 5 to 6 seconds, were seen occasionally. These conform to Type III duodenal waves (Foulk et al. l954; Vantrappen et al. l965; Friedman et al. l965); it was suggested that they should be designated tonic waves (Texter l968).

During both types of waves radiologically visible, circumferential narrowing of the luminal barium column occurred simultaneously with the increases in pressure (see also Chap. 15).

Fig. 13.2. Four monophasic duodenal pressure waves. Each was associated with a radiologically visible contraction. During each wave mucosal folds changed in direction to become longitudinal. Base line indicates intraluminal pressure in absence of motor activity. Ten-second marker on zero line


It was concluded that the narrowing of the intraluminal barium column was due to active contraction of the walls.

Living Anatomical Studies

The living anatomy was investigated in a number of patients who had to undergo cholecystectomy during the ordinary course of events (Keet and Heydenrych l982). The investigation was designed to determine the spatial relationship between the barium column in the lumen and the walls.

Ethical Considerations. The study was undertaken in informed, adult, white, volunteer patients who had been admitted to hospital with definite indications for cholecystectomy. All aspects of the procedure had been considered carefully beforehand by ourselves, our peers and the Head of the Department of Surgery; no objections were raised. The Ethical Committee indicated that it could find no objection to the procedure.

Patients, materials and methods

Six patients were examined. On completion of the cholecystectomy, and before closure of the abdomen, the stomach and duodenum were shown to be normal by means of direct inspection and palpation. Two fine, flexible stainless metal wires, similar to the wires used in the leads of myocardial pacemakers, were attached to the serosal surface of the pyloric region of the stomach and first part of the duodenum by means of superficial, interrupted, absorbable sutures (Fig. 13.3). One wire was attached to the lesser and the other to the greater curvature, the free "duodenal" ends of both wires being brought to the surface (as in the case of a postoperative T-tube) through the cholecystectomy incision, which was subsequently closed in the usual way.

Approximately 8 days later, on the day before discharge, each patient had a limited radiographic study as follows: after an overnight fast 4 to 5 mouthfulls of the usual liquid barium suspension was swallowed in the erect position, so as to outline the horizontal part of the gastric lumen and to extend well up into the vertical part. The space between the metal wires on the serosal surfaces and the luminal barium indicated the thickness of the wall; during the motor quiescent stage it was approximately 4.0 to 5.0 mm. After emptying into the duodenum had commenced, gastric contractions were studied by means of radiographic TV monitoring and appropriate radiographs.

Fig. 13.3. Radiograph showing living anatomy. Two fine, flexible metal wires (retouched) are attached to serosal surfaces of lesser and greater curvatures. The space between the wires and intraluminal barium indicates the cylindrical muscular contraction

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