The Pyloric Sphincteric Cylinder in Health and Disease



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Chapter 29 (page 142)

Case 29.2 I.H., 59 year old male, presented with longstanding epigastric pain and malaena. Radiographic examination showed a large ulcer in the posterior wall of the midcorpus. Endoscopic biopsy confirmed the ulcer; the gastric mucosa showed intestinal metaplasia with prominent acute and chronic inflammatory cells, diagnosed as subacute gastritis. No evidence of malignancy was found. After anti-ulcer therapy the patient was temporarily lost to follow-up, but reappeared three years later. Radiographic examination showed the following: after the first two mouthfuls of barium a large ulcer on the posterior wall of the corpus was evident as before (Fig. 29.2A). Before barium entered the duodenum a constant, deep spastic incisura was seen in the pyloric region of the distal greater curvature; swallowing more barium showed it to be due to contraction of the left pyloric loop (Fig. 29.2B). The pyloric sphincteric cylinder between the left loop and the pyloric aperture remained partially contracted, normal cyclical contraction and relaxation being absent. The pyloric aperture remained patent and emptying of fluid barium appeared normal; the appearances were unchanged throughout the examination.

Further treatment followed. Radiographic examination 18 months later showed the ulcer, the prominent contraction of the left pyloric loop and contraction of the remainder of the cylinder to be unchanged (Fig. 29.2C). Endoscopic biopsy confirmed the previous findings. Radiographic examination and endoscopic biopsy after another 5 years showed no change. Billroth II partial gastrectomy confirmed the presence of a large, chronic, benign gastric ulcer on the posterior wall of the corpus; it had penetrated into the pancreas. No organic lesion was seen or felt in the pyloric region.

Fig. 29.2 A,B. A Case I.H. Large gastric ulcer posterior wall of corpus (open arrow). Deep spastic incisura distal greater curvature (curved arrow). B Case I.H. The spastic incisura is caused by constant contraction of the left pyloric loop (curved arrow).

Fig. 29.2 C-F Case I.H. Eighteen months later the gastric ulcer (open arrow), contraction of the left pyloric loop (curved arrow) and contraction of the sphincteric cylinder are unchanged

Case 29.3 V.D., 30 year old male, complained of epigastric pain not responding to antacids. Radiographic examination showed a gastric ulcer 1.5cm in diameter, on the lesser curvature at the angulus (Fig. 29.3A); no signs of malignancy were seen. Intially there was marked contraction of the pyloric sphincteric cylinder, which contained a few prominent mucosal folds; this was associated with delay in emptying of liquid barium. After barium had filled the cylinder, it was seen to remain contracted throughout the examination; although a minor degree of relaxation occurred occasionally, the apperances remained as illustrated most of the time, with absence of cyclical activity (Fig. 29.3B). Longitudinal mucosal folds were evident in the contracted cylinder. Endoscopic biopsy showed a benign looking gastric ulcer in the corpus. Microscopically there was mixed inflammatory cell infiltration, diagnosed as acute on chronic gastritis. No evidence of malignancy was seen. Repeat endoscopy 2 months later showed that the ulcer had healed.

A
Fig. 29.3. A Case V.D. Gastric ulcer on lesser curvature at angulus (open arrow). Marked contraction of sphincteric cylinder (filled arrow). B Case V.D. Gastric ulcer at angulus (open arrow). Constant contraction of sphincteric cylinder (filled arrows) with absent cyclical activity. B



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