The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 20 (page 89)

Chapter 20


There has been much uncertainty about the concept "pylorospasm". For many years radiologists considered pylorospasm to be due to spasm of the pyloric ring, where the ring was equated with the pyloric sphincter. It was thought that spasm of the ring (or "sphincter") closed the pyloric aperture, thereby delaying gastric emptying and causing retention. In other words, whenever the barium-filled stomach showed delayed emptying, or failed to empty within a certain prescribed time (in the absence of an organic lesion), older radiologists were inclined to label the condition "pylorospasm". This diagnosis was made commonly, was usually accepted by clinicians, and probably had an erroneous bearing on the perception of many intra-abdominal conditions.

Radiological Features

Hughson (1925) for example, stated that spasm of the pylorus (as manifested by delayed gastric emptying) formed the basis of the radiological diagnosis in many pathologic conditions of the gastrointestinal tract. The great majority of cases of radiologically diagnosed pylorospasm were directly attributable to pathological conditions either of the stomach itself or of other abdominal viscera. He quoted previous studies in which radiological examinations had revealed delayed gastric emptying, considered to be due to pylorospasm, in 27 percent of duodenal ulcer and 89 percent of gastric ulcer cases. This led him to believe that radiologists had thrown much light on the relation of pylorospasm to intra-abdominal disease.

Bastianelli (1925) had reservations about the above radiological interpretation of pylorospasm. He agreed that in certain patients, especially neurotic individuals, a type of pylorospasm of nervous origin could occur; this was defined as a more or less permanent closure of the pylorus, not relieved by contractions of the "antrum" as seen at radiological examinations. It is clear that in this instance spasm of the pyloric ring was inferred. A similar type of pylorospasm was reflex spasm, occurring as a result of lesions of other abdominal organs, e.g. pathology of the gall bladder or appendix. In these cases there was increased tonicity of the pyloric canal and pyloric ring (the term "canal" indicated the pyloric aperture). Reflex spasm, causing a delay in gastric emptying, could also occur as a result of gastric hyperacidity. However, referring to the work of Cole (1913), Bastianelli (1925) stated that in many instances the radiological observations could not be accepted without question. Pylorospasm was much more likely to consist of a tonic contraction of the entire "antrum" rather than an isolated contraction of the "sphincter", as physiological observations favoured a simultaneous contraction of the whole region. It appeared to him that the question of pylorospasm needed revision.

Deaver and Burden (1929) were also impressed by the frequent radiological diagnosis of pylorospasm in intra-abdominal conditions (where pylorospasm was equated with spasm of the pyloric ring, which was considered to be the sphincter). It led these surgeons to believe that disease of the gall bladder or appendix caused symptoms which were attributable to reflex pylorospasm. It was assumed, moreover, that reflex pylorospasm prevented regurgitation of alkaline duodenal contents into the stomach, causing gastric hyperacidity and ulceration. In order to alleviate the symptoms in gastric ulceration, duodenal ulceration and chronic cholecystitis, the now obsolete operation of hemi- sphincterectomy was devised. During this procedure the anterior half of the pyloric "sphincter" (i.e. the pyloric ring) was excised; in their view this prevented further pylorospasm and relieved the symptoms in most cases.

Problems of Definition

What exactly is meant by pylorospasm? During conventional radiological examinations, with the patient in the erect position, and in the absence of an organic lesion in the upper gastrointestinal tract, it is not unusual to observe a delay in gastric emptying of liquid barium suspension. This, in many instances, is still considered to be caused by pylorospasm, by which is implied spasm of the pyloric ring, which is equated with the sphincter. The question may well be asked whether the ring is spastic in these cases. If it were, it could be expected to remain spastic irrespective of the position of the patient. In order to determine whether this is the case, the following investigations were done.

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