The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 27 (page 127)


The main advantages of this method appear to be the following:

  1. Because of the clear images produced by radiography, the diameter and competence of the pylorus may be studied in relation to both duodenal contraction waves and the motility of the pyloric part of the stomach, i.e. the pyloric sphincteric cylinder. Little attention has been paid to duodenogastric reflux in relation to pyloric motility in previous investigations.

  2. If it is assumed that the barium suspension in the duodenal lumen represents duodenal contents, the procedure will determine the presence or absence of reflux of duodenal contents, i.e. of duodenal juice (in contrast to bile only).

  3. No medication (e.g. anticholinergics or cholecystokinin) is administered, thus allowing the study of pyloric competence in the absence of pharmacological modification.

  4. There is no gastric intubation (thus eliminating nausea) and the pylorus is not traversed by a tube (or has been traversed immediately before observation, as in the test of Keighley et al. l975).

  5. The test is quick and simple to perform, and may be followed by a "conventional" upper gastrointestinal radiographic examination.


  1. Radiation to the patient should be considered, but measurements showed that this was minimal and could be discounted since a small (11.0 x 8.0 cm), localized aperture was used, not more than two 11.0 x 8.0 cm film exposures were needed for record purposes, and screening time generally did not exceed 90 to 120 seconds.

  2. In a minority of patients, depending on the direction of the pyloroduodenal axis, it may not be possible to obtain a side view of the duodenum and pylorus, the barium-filled bulb being projected over the pyloric aperture.

  3. The examination is performed in the interdigestive phase and in the supine position only.

  4. While there is no doubt about the ability of the procedure to illustrate the presence or absence of reflux, quantification cannot be accurate as only a rough impression of the quantity of reflux is gained.

Results in Normal Subjects

Having received approval of the Ethical Committee, the test was performed in 14 informed, volunteer, asymptomatic male medical students between the ages of 23 and 27 years. In 9 of the subjects no duodenogastric reflux occurred. In 2 subjects there was minimal reflux on one occasion only (three further "rotating manoeuvres" failed to produce reflux). In 3 subjects moderate reflux occurred. In each it was seen two or three times during four "rotating manoeuvres". One of these subjects was re-tested a week later, with similar results.

Duodenal Motility

In all 14 normal subjects duodenal peristalsis appeared normal on the TV monitor and the duodenum emptied normally. In all there also occurred retrograde movement of barium in the duodenal lumen, which appeared to result from "segmental" contraction waves in the third part of the duodenum. While these contractions did not proceed along the duodenal walls, but remained localized to the third part, they forced barium in an orad direction, at times as far as the bulb; barium in the lumen distal to these contractions was forced in an aborad direction.

In all normal subjects the second part of the duodenum was also compressed as far as possible by means of the gloved hand on the anterior abdominal surface. This did not occlude the lumen completely, did not prevent aborad movement, and did not initiate retrograde movement. The results were the same with and without partial compression of the second part of the duodenum.

Pyloric Motility

As indicated previously (Chap. 3), the muscular part of the pyloric ring is considered to be the terminal annular thickening of the pyloric sphincteric cylinder, as described by Cunningham (1906), Forssell (l913) and Torgersen (l942). The cylinder, which is 3.0 to 4.0 cm in length, normally contracts in a segmental (as opposed to "peristaltic") way (Chap. 13). As the ring forms an inherent part of the cylinder, it closes and opens with contraction and relaxation of the cylinder respectively. In all subjects these contractions were normal. Reflux in the 5 subjects occurred either during maximal relaxation of the sphincteric cylinder, (Fig. 27.2), or when it was in a state of partial contraction (Fig. 27.3). It never occurred during maximal contraction of the cylinder.

Fig. 27.3. Barium filling to show partial contraction of sphincteric cylinder. At this stage the pyloric aperture (arrow) is widely patent

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