The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 29 (page 141)

In a further study of the pathomorphology of the antropyloric wall in peptic ulcer disease, Liebermann-Meffert and Allgöwer (l98l) found that abnormalities of the muscle fibres and Auerbach's plexuses, and the replacement of contractile muscular tissue by fibrous tissue, might impair antropyloric motor function, having a bearing on gastric emptying and duodenogastric reflux. The changes were always more severe in gastric than in duodenal ulceration, and did not occur in controls. While the pyloric aperture was somewhat rigid to distension in all peptic ulcer patients, its mean diameter was not significantly smaller than in controls and there was no stenosis of the pyloric ring which could account for gastric stasis.

Miller et al. (l980) pointed out that while patients with Type I gastric ulcers had less acid in their stomachs than normal controls, it was debatable whether this indicated actual hyposecretion, or whether it was due to increased back-diffusion of hydrogen ions across the mucosal barrier, or to neutralization by refluxed duodenal contents. In a study of 7 patients with chronic benign gastric ulceration above the incisura, it was found that gastric acid output in response to an ordinary solid-liquid meal was significantly less than in normal controls. In the patient group the emptying rate of solids was consistently lower than in controls while emptying of liquids remained normal. The gastric ulcer patients also had increased intragastric bile acid concentrations.

In his review Brooks (l985) found that a gastric ulcer in the corpus was usually associated with hyposecretion of acid and pepsin, decrease in the "antral" gastrin content, reduced amplitude of "antral" contractions, an incompetent pylorus, increased bile reflux, and delayed emptying of solids.

We have noted that gastric ulcers in the more proximal parts of the stomach were sometimes associated with contraction or motility disturbances of the pyloric sphincteric cylinder. The following are representative cases:

Case Reports

Case 29.1 C.W., 60 year old male, presented with intermittent epigastric pain and malaena. Radiographic examination showed a gastric ulcer, 2.5 cm in diameter, in the posterior wall of the upper corpus, approximately 10 cm proximal to the pylorus; the features were those of a benign ulcer. There was constant contraction (or spasticity) of the pyloric sphincteric cylinder, the contracted region being 3.0 to 4.0 cm in length (Fig. 29.1). Cyclical contraction and relaxation of the cylinder, normally occurring at a rate of 3 cylces per minute, was absent; the contraction of the cylinder "fixed" the pyloric aperture in the open or patent position. Mucosal folds in the contracted cylinder appeared normal, but their movements were restricted. A shallow, concave identation of the base of the duodenal bulb, caused by the pyloric ring, was evident. Peristaltic waves in the remainder of the stomach were normal; emptying of liquid barium appeared normal. Two weeks later a Billroth I partial gastrectomy confirmed the large, chronic gastric ulcer. No macroscopic abnormality was seen or felt in the pyloric region. Histology of the ulcer proved it to be benign; microscopic examination of the pyloric region was not carried out.

Fig. 29.1 A-D. Case C.W. Constant contraction or spasticity of pyloric sphincteric cylinder. Cyclical activity absent. Pyloric aperture "fixed" in patent position (B-D)

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