Chapter 20 (page 93)

The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 20 (page 93)

Case 20.4. J.P.W., 78 year old male was referred for upper gastrointestinal barium examination because of early satiety and poor appetite, with the provisional diagnosis of gastric carcinoma. No organic lesion was seen but there was a constant contraction of the pyloric sphincteric cylinder, containing longitudinal mucosal folds (Fig. 20.4). At times it relaxed somewhat but the range of rhythmic contraction and relaxation was severely restricted and normal cycles of maximal contraction and relaxation at a rate of 3 per minute did not occur. Gastroscopy was completely normal and the diagnosis of spasm of the pyloric sphincteric cylinder was made.

Fig. 20.4. Case J.P.W. Spasm of pyloric sphincteric cylinder. Gastroscopy revealed no organic lesion

Case 20.5. H.O., 69 year old female, a known case of polycythaemia vera, splenomegaly, hepatomegaly and cholelithiasis, underwent cholecystectomy at which the stomach was proved to be normal. Because of a feeling of fullness in the epigastrium an upper gastrointestinal barium series was requested 10 days post-operatively. There was a persistent contraction of the pyloric sphincteric cylinder; occasionally it contracted maximally but never relaxed more than illustrated (Fig. 20.5). Normal cyclical contractions of the cylinder at 3 per minute were absent. The partial contraction of the cylinder fixed the pyloric aperture in the open position; at times duodenogastric reflux occurred through the patent pyloric aperture and contracted cylinder (Chap. 27). The contraction was associated with a concave impression of the base of the duodenal bulb. In view of the absence of an organic gastric lesion at operation, the condition was diagnosed as simple spasm of the pyloric sphincteric cylinder.

Fig. 20.5. Case H.O. Spasm of pyloric sphincteric cylinder. Pyloric aperture fixed in patent position. Intermittent duodenogastric reflux. No gastric lesion detected at cholecystectomy

Case 20.6. W.J.G., 76 year old female was referred for radiographic studies because of loss of appetite. There was partial contraction of the pyloric sphincteric cylinder throughout the examination with absence of normal cyclical activity (Fig. 20.6). A prominent circumferential mucosal fold in the contracted cylinder raised the possibility of associated gastritis (Chap. 28). Gastroscopy showed no abnormality; it was noted that the pyloric aperture remained patent. At control barium studies a fortnight later the contraction had disappeared and normal cyclical activity was seen. The initial appearance was diagnosed as spasm of the pyloric sphincteric cylinder.

Fig. 20.6. Case W.J.G. Contracted pyloric sphincteric cylinder with prominent mucosal fold (arrow). Gastroscopy showed no organic lesion

Discussion

Accumulated evidence shows that it is very unlikely, if not impossible, for the pyloric ring as such, to become spastic. Anatomically the ring is not a purely muscular structure, but consists of muscular and mucosal/submucosal components (Chap. 11).

Cunningham (l906), Forssell (l913) and Torgersen (l942) showed that its muscular component is not a separate anatomical structure, but merely the aboral thickening of the musculature of the sphincteric cylinder. There is no dividing line between its musculature and that of the remainder of the cylinder. On anatomical grounds isolated spasm of the ring, without spasm of the entire cylinder, would be difficult to envisage.

Manometrically Atkinson et al. (l957) and others (Chap. 15) found that the ring did not act as a physiological sphincter in the sense that it caused a band of increased pressure and that it was capable of independent contraction. Contraction of the ring occurred only as part of intermittent, phasic contractions of the "whole pyloric region" (presumably the sphincteric cylinder).