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Chapter 27 (page 130)
Du Plessis (l965) found the concentration of bile acid conjugates in fasting gastric
aspirates to be abnormally high in cases of gastric ulceration. Capper et al. (l966) found
moderate or gross reflux in 66 percent of gastric ulceration patients, while Rhodes et al
(l969) and Delaney et al. (l970) mentioned an increased incidence of bile reflux in
patients with gastric ulceration. Flint and Grech (l970) stated that the pylorus was
incompetent in gastric ulceration and chronic alcoholic gastritis, while the results of
Valenzuela and Defilippi (l976) suggested pyloric "sphincter" incompetence in gastric
ulceration. Nicolai et al. (l980) found increased reflux in l8 gastric ulcer cases.
In our series (Keet l982) there were 9 cases of benign ulcer on the lesser curvature of the
stomach at varying distances proximal to the sphincteric cylinder, i.e. not within the
cylinder. Seven of these showed moderate reflux. In the series of Hughes et al. (l982)
reflux was present in 21 of 46 patients with gastric ulcer. Although there appeared to be
a higher proportion of gastric ulcer patients with reflux, the results did not reach
statistical significance when compared with the other dyspeptic patients examined. The
impression was that there was no direct association between the degree of reflux and the
presence of peptic ulceration, according to Hughes et al. (l982). Niemela et al. (l984)
found that of l9 patients with gastric ulcer in the body of the stomach, l7 had reflux. Two
patients had both gastric and duodenal ulceration, both showing reflux. Twelve patients
had prepyloric and antral gastric ulcers, 8 showing reflux. Of 30 patients with gastric
ulceration Wolverson et al. (l984) found l7 (53 percent) to be reflux positive. Gotthard et
al. (l985) examined 11 patients with prepyloric ulcer disease (i.e. with the ulcer situated
within 2.0 cm of the pyloric ring); in all the intragastric concentrations of bile acid were
measured over a 12 hour period. The mean bile acid concentrations in prepyloric ulcer
patients were found to be significantly higher than in both controls and duodenal ulcer
patients, diurnally as well as nocturnally.
Gastric ulceration is often associated with spasm of the pyloric sphincteric cylinder
(Chap. 29). Spasm of the cylinder resembles a normal, partial contraction; at this stage
the pyloric aperture is normally open (Chap. 13). In spasm the aperture is "fixed" in the
open position. It is surmized that for this reason a high incidence of duodenogastric
reflux is to be expected in gastric ulceration.
Malignant Gastric Ulceration
In our series (Keet l982) 2 malignant gastric ulcers were found. In one case, with the
ulcer on the gastric 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 Gastro-Oesophageal Reflux
Donovan et al. (l977) noted duodenogastric reflux in 3 of 8 patients with hiatus hernia. In
10 cases of hiatus hernia Nicolai et al. (l980) found no evidence of increased reflux. In
our series (Keet l982) there were 9 cases of hiatus hernia, 4 showing reflux of duodenal
contents. There seems to be an association between hiatus hernia and spasm of the
pyloric sphincteric cylinder; this may allow increased duodenogastric reflux and may
ultimately lead to biliary oesophagitis (Chap. 32).
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 showed a constant spasm of the
pyloric sphincteric cylinder with irregular and transverse mucosal folds (Fig. 27.4). It
was diagnosed radiologically and endoscopically as spasm and 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 the
Both in normal controls and in patients, duodenogastric reflux 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. During relaxation of the cylinder
there is absence of muscular closure of the aperture; mucosal closure may be present
(Chap. 13). During partial contraction of the cylinder, occurring as a phase of cyclical
contractile activity, the pyloric aperture is open (Chap. 13). Spasm of the cylinder
resembles partial, physiological contraction, and is associated with patency of the
aperture; it differs from a physiological contraction in that its contraction is permanent.
Consequently increased duodenogastric reflux is to be expected in spasticity of the
pyloric sphincteric cylinder.
The above does not imply that the phase of contraction of the sphincteric cylinder is the
only factor in the pathogenesis of duodenogastric reflux.
Both in normal subjects and in patients, duodenal peristaltic waves and "segmental"
contraction waves in the third part of the duodenum appeared to be of little consequence
in duodenogastric reflux (vide supra). However, in experimental studies in canines
Ehrlein (l981) found that the timing between contractions of the duodenal bulb and the
pyloric "sphincter" (right pyloric loop) was not perfect. Contraction maxima of the
duodenal bulb often occurred slightly before or after contraction maxima of the "sphincter".
Consequently the pyloric aperture was often inadequately closed during contraction of
the duodenal bulb, resulting in reflux.
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