The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 20 (page 94)

Radiographically it was shown in 49 of 50 cases of so-called pylorospasm that spasm of the ring did not exist and that the aperture, in fact, was widely patent. The lack of peristalsis, lack of cyclical contractions of the sphincteric cylinder and delayed emptying in these cases could be explained on the basis of gastric hypotonicity (Chap. 19). It seems probable that in the past many cases have been diagnosed incorrectly as reflex "pylorospasm" (where pylorospasm was equated with spasm of the pyloric ring). Far from throwing much light on the relationship of pylorospasm to intra-abdominal disease, as Hughson (l925) would have it, radiology seems to have led to confusion in these cases.

It is clear, on the other hand, that spasm of the pyloric sphincteric cylinder as a whole, can and does occur. Torgersen (l942) was one of the first to draw attention to this entity and to explain the morphology on the basis of the underlying anatomy. Well documented cases have subsequently been described by Astley (l952), Wood and Astley (l952) and Craig (l955); the spasm of the "antropyloric region" described by Swischuk (l978, l980) and the infantile pylorospasm mentioned by Franken (l982) appear to be of a similar nature.

Although Larson et al. (l967) and Bateson et al (l969) did not refer to the pyloric sphincteric cylinder, it appears if the "antral" contractions which they observed at operation, were limited to this muscular entity. The temporary contraction or spasm described by Keet and Heydenrych (l97l) during experimental stimulation of the vagus trunks, clearly involved the sphincteric cylinder. The cylindrical contractions of the "distal antrum" and pylorus noted by Blumhagen and Coombs (l98l) and Blumhagen and Noble (l983) at ultrasonography, was called pylorospasm. It was not explained on the basis of the underlying anatomy as determined by Cunningham (l906), Forssell (l913) and Torgersen (l942), but, according to the description, appeared to involve the sphincteric cylinder. Ultrasound measurements of the "length of the pyloric muscle" (Wilson and Vanhoutte l984; Graif et al. l984) and the length of the "pyloric canal in its most contracted state" (Stunden et al. l986) also point to the existence of a muscular cylinder, which is liable to undergo spasm (Haller and Cohen l986).

Five new cases of pylorospasm in infants and adults in which spasm clearly involved the pyloric sphincteric cylinder have been described here.

It is concluded on anatomical, physiological, manometric, sonographic and radiographic evidence that spasm of the pyloric ring per se, is unlikely to occur; spasm of the entire pyloric sphincteric cylinder, on the other hand, can be demonstrated clearly.

One of the consequences of spasm of the sphincteric cylinder is that the pyloric aperture may be fixed in the open or patent position (Chap. 13); this may be a factor in the occurrence of duodenogastric reflux (Chap. 27). One of the adult cases described here had visible duodenogastric reflux and one of the infants presented with persistent bile- stained vomiting, indicating bile reflux.

Spasm of the cylinder implies absent or decreased cyclical contractions of this part of the stomach, normally occurring at a rate of 3 per minute in man (Chap. 13). This fact may readily be established during radiographic examinations. Decreased cyclical activity of the cylinder may lead to impaired trituration and delayed emptying of solids (Chap. 18).


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