The Pyloric Sphincteric Cylinder in Health and Disease



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Chapter 22 (page 101)

Barium radiographic examination at that time showed a small diverticulum on the greater curvature of the pyloric sphincteric cylinder approximately 2.5 cm proximal to the pyloric ring (Fig. 22.1A). Its neck, which was surrounded by a shallow, smooth-walled indentation of the barium in the lumen, was 0.7 mm in diameter. During contraction of the cylinder it was seen to be situated midway between the right and left pyloric loops (Fig. 22.1B) in the situation where the pyloric pseudo-diverticulum occurs normally (Chap. 13). At times, during near maximal contraction of the cylinder, it disappeared, only to reappear during the next cycle of filling.

AB
Fig. 22.1. A Case M.W. Small intramural diverticulum (arrow) on greater curvature of pyloric sphincteric cylinder 2.5 cm proximal to pyloric ring. B Case M.W. Partial contraction of sphincteric cylinder. Intramural diverticulum (arrow) situated on rim of physiological pseudodiverticulum (PD), midway between right and left pyloric loops

Because of the features enumerated in the discussion it was diagnosed as an intramural or partial gastric diverticulum. It was certainly not an ulcer as witnessed by repeated gastroscopies. The fact that it was not seen at gastroscopy does not come as a surprise as Treichel et al. (l976) had found that the lesion was easier to detect by radiography than by endoscopy. Cockrell et al. (l984) stated that an intramural diverticulum may be difficult to detect endoscopically if its ostium is hidden by a fold or if it occurs in an area which is contracting.

Case 22.2. G.V., 32 year old female, complained of a vague feeling of fullness and occasional pain in the epigastrium. Physical examination revealed some epigastric tenderness. After a month's treatment with antacids the symptoms disappeared. Radiographic examination at that time showed a small diverticular-like structure on the greater curvature of the pyloric sphincteric cylinder approximately 3.0 cm proximal to the pyloric ring, i.e. midway between the right and left pyloric loops, in the position where the pyloric pseudo-diverticulum usually occurs (Fig. 22.2A). It was surrounded by a shallow, smooth-walled, lenticular indentation of the barium in the lumen. During contraction of the cylinder it changed in shape and became smaller (Fig. 22.2B); it was diagnosed as an intramural or partial diverticulum. Absence of associated spasm, normal mucosal folds in the vicinity and change in size during contraction ruled out an ulcer. The patient was lost to follow-up and did not return for gastroscopy.

AB
Fig. 22.2. A Case G.V. Intramural diverticulum (arrow) on greater curvature of sphincteric cylinder 3.0 cm proximal to pyloric ring. B Case G.V. Contraction of sphincteric cylinder. Intramural diverticulum (arrow) between right and left pyloric loops now smaller

Case 22.3. J.V., l9 year old female, complained of "acidity", of several months' duration. Gastroscopy showed mucosal erosions in the lower oesophagus, probably due to reflux oesophagitis. The gastric fornix and corpus were normal; on the greater curvature of the "antrum" a "pseudodiverticulum" was seen. Radiographic examination 14 months later, for the same complaint, showed an intramural diverticulum on the greater curvature within 2.0 cm of the pylorus. Cyclical contractions of the pyloric sphincteric cylinder were normal; during contraction of the right and left pyloric loops, a normal, physiological pseudodiverticulum was seen with an intramural diverticulum on its greater curvature aspect (Fig. 22.3).

Fig. 22.3. Case J.V. Normal contraction of pyloric muscle torus (MT) and right (RPL) and left (LPL) pyloric loops. Intramural diverticulum (arrow) on rim of physiological pseudodiverticulum (PD)



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