Chapter 28 (page 136)

The Pyloric Sphincteric Cylinder in Health and Disease

Go to chapter: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | 39
Chapter 28 (page 136)

Case 28.5 J.M., 45 year old male. The pyloric sphincteric cylinder remained partially contracted throughout the radiographic examination, with complete absence of normal, cyclical contraction and relaxation. At least one prominent, circumferential mucosal fold, which did not change in position, was present in the partially contracted cylinder (Fig. 28.5). Initially it was difficult to distinguish between a permanent, circumferential mucosal fold and a prepyloric septum. Endoscopy revealed prominent, thickened prepyloric mucosal folds with an abnormal, whitish, granular surface. Endoscopic biopsy showed lymphocytic and plasma cell infiltration of the lamina propria; in some areas atypical epithelium, presumably due to inflmmatory change, was seen. The endoscopic diagnosis was chronic "antral" gastritis.

Fig. 28.5. Case J.M. Partial contraction of sphincteric cylinder, with absent cyclical activity. Prominent static, circular mucosal fold in cylinder (arrow)

Discussion

A brief review of the literature shows that many aspects of gastritis are still controversial; even its definition is contentious. It has been stated that clinicians, pathologists and endoscopists defined "gastritis" in different ways (Hojgaard et al. l987). Others held that the term "chronic gastritis" had different connotations for the clinician, the pathologist and radiologist (Rao et al. l975). Authors differ on the subdivision of gastritis into various types and grades. It is agreed, however, that the diagnosis in the intact stomach can only be made by means of endoscopy, biopsy and microscopy. As the deeper layers of the wall are also involved in many instances, a full investigation would entail histologic examination of resection specimens.

The cases quoted here show that certain radiologically recognizable alterations may be associated with chronic "antral" gastritis, perhaps more correctly termed chronic gastritis affecting the pyloric sphincteric cylinder. (One of the cases was diagnosed as erosive haemorrhagic gastritis). The radiologically recognizable alterations are:

Partial but constant contraction of the sphincteric cylinder; the degree of contraction was usually described as "moderate" or "marked". In these cases radiologically visible peristaltic waves in the corpus and sinus of the stomach appeared normal, but each wave stopped at the commencement of the partially contracted cylinder. In some cases the cylinder showed minor degrees of contraction and relaxation, but maximal cyclical contraction and relaxation at a rate of 3 cycles per minute was absent in all. The appearance closely resembles that of pylorospasm (Chap. 20).

In some cases the pyloric aperture was seen to be fixed in the open position as a consequence of partial contraction of the cylinder; this appearance may be associated with duodenogastric reflux (Chap. 27). It is presumed that the lack of cyclical activity of the cylinder may have a bearing on trituration and the emptying of solids (Chap. 18).
Prominent irregular and/or circular mucosal folds showing restricted movements or no movement at all. In view of the restricted movements of the walls of the cylinder it is not surprising that "independent but co-ordinated" movements of the inner mucosal layer should also be curtailed or absent (Chaps. 2, 13). It is surmized that cellular infiltration in the mucosa, submucosa, muscular layers and neuronal elements occurring in chronic gastritis, partially accounts for the restricted movements.

Theoretically the static, irregular mucosal folds projecting into the lumen should hamper duodenogastric reflux occurring as a result of patency of the pyloric aperture in some cases.
A presumptive radiological diagnosis of chronic gastritis affecting the sphincteric cylinder, was only made if the above features occurred in the absence of other pathology in the upper gastrointestinal tract (e.g. gastric ulceration or hiatus hernia).

According to Nesland and Berstad (l985) and Karvonen et al. (l987), erosive prepyloric change (EPC) was a condition characterized by standing mucosal folds and erosions; it was diagnosed endoscopically and appeared to be an entity of its own. Radiographically a standing mucosal fold may also be recognized, as seen in Fig. 28.5. In this case it concerned a circular fold which failed to change in position. It was associated with lymphocytic and plasma cell infiltration, no mention being made of erosions.