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 20 (page 90)

Patients and Methods

Fifty adult, ambulatory out-patients, each showing a long, "hanging", atonic stomach with a marked delay in gastric emptying of liquid barium in the erect position (an appearance usually ascribed to pylorospasm), were selected for examination. These patients were encountered during the ordinary course of events, having been referred for routine radiographic study because of vague upper abdominal symptoms. None had any objective signs of upper gastrointestinal disease at a prior clinical examination. The following is a representative case:

Case Report

Case 20.1.J.B., 47 year old male. After swallowing the first 3 mouthfuls of Micropaque in the erect position, the stomach was seen to be of the long, hanging, atonic type, the sagging greater curvature forming the most dependent part (Fig. 20.1A). The distal part of the stomach curved upwards and was filled up to the presumed position of the pyloric ring. Peristalsis and cyclical contractions of the pyloric sphincteric cylinder were absent, with total absence of gastric emptying for the first 5 minutes. This would have been interpreted as "pylorospasm" by many investigators. The head of the examining table was then lowered to an angle of 45 degrees, while the patient was rotated 45 degrees onto the right side (i.e. the tilted left anterior oblique radiological position). Immediate emptying of liquid barium occurred in the continued absence of both peristalsis and contractions of the pyloric sphincteric cylinder, revealing a normal pyloric ring surrounding a patent aperture (Fig 21.1B). On re-assuming the erect position, gastric emptying ceased once again.

Fig. 20.1. A Case J.B. Erect position. Long, atonic stomach, the sagging greater curvature forming most dependent part. Absence of peristalsis, cyclical activity of sphincteric cylinder and emptying of fluid barium. B Case J.B. Oblique tilted position. Normal pyloric ring and patent aperture. Immediate emptying of fluid barium in continued absence of peristalsis and cyclical activity of sphincteric cylinder

In 49 of the patients the features were identical to the case quoted. The findings show that the delay in gastric emptying was not due to pylorospasm, in the sense that the pyloric ring was spastic, as neither spasm nor delayed emptying was present in the tilted oblique position; it would be highly improbable for spasm to manifest itself in the erect position only. It was much more likely that the delay in gastric emptying was due to one or both of the following factors: (1) primarily aperistaltic, hypotonic stomach; (2) the erect position of the subject. In these cases, in the erect position, the pyloric aperture is at a higher level than the lowermost part of the greater curvature, which bulges downward. While the aperture is patent, the lack of tone (Chap. 19) and/or cyclical contractions of the pyloric sphincteric cylinder (Chap. 18) causes failure of emptying. In the tilted oblique position the aperture is manipulated so as to become the lowermost part of the stomach. While contractions of the cylinder remain absent, passive, gravitational emptying of liquid content occurs, showing the aperture to be patent, without evidence of spasm of the ring. (In one of the 50 cases a delay in gastric emptying occurred in both the erect and the tilted oblique positions; the cause of this remained unclear.)


It appears possible that Hughson (l925), Deaver and Burden (l929) and others were led to believe that absent or delayed emptying of fluid barium in hypotonic stomachs in the erect position, was due to pylorospasm, which was equated with spasm of the pyloric ring. It was claimed, moreover, that such "pylorospasm" was a frequent accompaniment of intra-abdominal pathology. In the historical context it is of interest to note that Bastianelli (l925) questioned their radiological interpretation of "pylorospasm". Even today an inactive, hypotonic, barium containing stomach showing delayed or absent emptying in the erect position is often, and we believe mistakenly, ascribed to pylorospasm. According to Torgersen's views (l942) it would be highly unlikely for the pyloric ring (the right pyloric loop) as such, to become spastic; as no dividing line exists between the musculature of the ring and that of the remainder of the sphincteric cylinder, any possible spasm would involve the entire cylinder.

Previous Page | Table of Contents | Next Page
© Copyright PLiG 1998