Chapter 27 (page 128)

The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 27 (page 128)

Results in Patients

Having received approval of the Ethical Committee, the test was performed in 100 patients between the ages of l8 and 79 years who, during the ordinary course of events, had been referred for radiographic examinations because of upper gastro-intestinal symptoms, e.g. dyspepsia and epigastric pain.

No Lesion Detected

In 48 patients no macroscopic organic lesion could be demonstrated in the upper gastro- intestinal tract; these were considered to be patients with non-ulcer dyspepsia. Eighteen (± 37 percent) had minimal to moderate duodenogastric reflux. In all cases reflux occurred during those stages of the pyloric cycle in which the pyloric sphincteric cylinder was relaxed (Fig. 27.2), or partially contracted (Fig. 27.3). Reflux never occurred during maximal contraction of the cylinder.

Duodenal Ulceration

In our series there were 25 cases of active duodenal ulceration or duodenal deformity typical of ulceration, l8 (approximately 72 percent) showing moderate duodenogastric reflux.

Gastric Ulceration

We encountered 9 cases of chronic benign ulcer on the lesser curvature of the stomach at varying distances proximal to the pyloric sphincteric cylinder, i.e. not within the cylinder itself. Seven of these showed moderate reflux. In the present series no cases of benign gastric ulceration within the pyloric sphincteric cylinder were seen.

Malignant Gastric Ulceration

In our series 2 cases of malignant gastric ulceration (proved by biopsy) were diagnosed. In one case, with the ulcer on the lesser curvature close to the pylorus (i.e. within the sphincteric cylinder), there was moderate to marked reflux. In the second case, with the ulcer at the incisura angularis, no reflux was seen.

Sliding Hiatus Hernia with Free Gastro-Oesophageal Reflux

There were 9 cases in the present series, 4 showing reflux of duodenal contents into the stomach.

Combined Lesions

In the present series 7 cases had combined lesions, e.g. duodenal ulceration and hiatus hernia. Most of these showed reflux. One of these cases had constant spasticity of the pyloric sphincteric cylinder with irregular and transverse mucosal folds (Fig. 27.4). It was diagnosed radiologically and endoscopically as spasm and chronic gastritis affecting the cylinder. In addition the duodenal bulb was deformed due to ulceration. In this case moderate to marked duodenogastric reflux occurred. Owing to the tube-like spasm of the cylinder, the pyloric aperture was neither fully open nor fully closed, but fixed in a state of partial patency.

Fig. 27.4. Barium filling of spastic pyloric sphincteric cylinder in a case of chronic gastritis. Duodenal bulb deformed

Duodenal Motility

In the last 40 patients of the series, special attention was paid to duodenal motility. In 32 of these the aborad and orad movements of intraluminal barium were identical to those in normal controls. In 8 no orad movement of contrast was seen in the second and third parts of the duodenum, yet in half of these cases duodenogastric reflux occurred. One's impression was that physiological duodenal movements were probably of little consequence in the mechanism of reflux. (By experimentally reversing the pacesetter potential in the duodenum in canines by electrical stimulation, Kelly and Code l977 did produce reflux.)

Pyloric Motility

As in normal control subjects, reflux in patients only occurred while the pyloric sphincteric cylinder was relaxed or in a state of partial contraction; it never occurred during maximal contraction of the cylinder.