The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 24 (page 116)

Associated Lesions

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).

Relationship to Infantile Hypertrophic Pyloric Stenosis

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.

Anatomical Localization and Operative Features

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).

Radiographic Features

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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