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Chapter 24 (page 116)
Gastric Ulceration
It is seen (Table 24.2) that the most common associated lesion is gastric ulceration, followed
by duodenal ulceration, hiatus hernia, chronic atrophic or haemorrhagic gastritis, pyloric
ulceration, gall bladder pathology, gastric mucosal prolapse and gastric carcinoma, in
decreasing order of frequency. Although this is not stated unquivocally in all cases, it
appears that in most the gastric ulcer was situated some distance away from, i.e. proximal
to, the pyloric region (North and Johnson l950; Craver l957; McNaught l957; Skoryna
et al. l959; Knight l96l; Bateson et al. l969). A number of authors held the view that
pyloric stenosis was the primary event, with ulceration developing as a result of stasis
and retention of gastric acid and pepsin (Wieser et al. l963; du Plessis l966; Levin l97l).
This view is open to doubt. It has been shown that gastric ulceration in the body of the
stomach was sometimes associated with motility disturbances or spasm of the pyloric
sphincteric cylinder (Chap. 29). An alternative explanation, in our view, is that gastric
ulceration may, by some as yet unknown mechanism, cause motility disturbances of the
cylinder, eventually leading to muscular hypertrophy.
Hiatus Hernia
Of 44 cases of AHPS described by Wieser et al. (l963), 20 percent had an associated
hiatus hernia. Bodon and Haake (l968) described a group of 11 cases in which hiatus
hernia was associated with AHPS. This supports the view that there may be an
association between lesions of the gastric fornix and the pyloric sphincteric cylinder
(Chap. 32).
Primary AHPS may arise de novo in adult life, or it may be a sequel to infantile
hypertrophic pyloric stenosis (IHPS) (Lumsden and Truelove l958; Levin l97l).
A number of authors found that the lesion in AHPS was almost identical, comparable or
similar to that of IHPS (North and Johnson l950; Craver l957; McNaught l957; Seaman
l963). Christiansen and Grantham (l962) and Heinisch (l967) stated that the gross and
histological appearances of AHPS were indistinguishable from those of IHPS; according
to Keynes (l965) the appearance of both the simple and complicated varieties of AHPS
was similar to that of IHPS.
In operative and pathological specimens the muscular hypertrophy was thickest at the
pyloric ring, ending abruptly at the duodenum, but decreasing gradually over the
"antrum" (North and Johnson l950; Seaman l963; Keynes l965). The muscular
hypertrophy, extending in an orad direction from and including the pyloric ring, was said
to be 2.5 to 3.0 cm in length by Morton (1930), 3.0 to 4.0 cm by North and Johnson
(l950) and Craver (l957), 2.5 cm by Knight (l96l) and from 1.0 to 5.0 cm by Bodon and
Haake (l968). Bateson et al (l969) called it a tube-like narrowing of the pyloric ring and
immediate prepyloric musculature, 2.5 to 3.0 cm in length; as the "pyloric and
prepyloric" musculature was involved, they suggested it should be termed hypertrophic
pyloric channel disease.
These findings leave little doubt that the muscular hypertrophy in AHPS encompasses the
musculature of the pyloric sphincteric cylinder. A number of authors, viz. McNaught
(l957), Skoryna et al. (l959), Seaman (l963), Wieser et al. (l963), Keynes (l965) and du
Plessis (l966) based the morphology of AHPS on the anatomy as determined by
Torgersen (l942). Many other authors, however, did not relate their findings to the
anatomy as described by Cunningham (l906), Forssell (l913), Cole (l928) and Torgersen
(l942).
As the radiographic features of IHPS are quite reliable, it would be reasonable to expect
that the same would hold true for AHPS. However, this is not usually the case. Kirlin
and Harris (l933) mentioned elongation and narrowing of the pyloric canal with partial
gastric outlet obstruction as some of the more familiar appearances, with a concave
indentation of the base of the duodenal bulb (caused by invagination of the hypertrophied
musculature) as a distinctive radiological sign. (Comment: The description
"elongation of the pyloric canal" was discussed in Chapter 23. It appears to be as
inappropriate in AHPS as it is in IHPS. A concave indentation of the base of the
duodenal bulb may also be seen under other circumstances, e.g. maximal normal
contraction of the pyloric sphincteric cylinder, as described in Chapter 13). Associated
lesions, e.g. gastric ulceration or hiatus hernia, may be demonstrable radiographically.
Larson et al. (l967) pointed out that the carefully executed studies of Seaman (l963)
revealed data that should prove disquieting to the radiologist who attempted an
unqualified diagnosis of AHPS. There was little correlation between the length and
width of the pyloric "canal" as seen on radiographs in these cases, and as measured in
surgical resection specimens. Levin (l97l) found that the radiographic diagnosis of
AHPS could seldom be made with confidence.
No reports of ultrasound investigations in AHPS have been encountered.
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