Chapter 29 (page 143)

The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 29 (page 143)

Discussion

Chronic Benign Gastric Ulceration

Many authors found evidence of chronic or atrophic gastritis in the pyloric region in cases where gastric ulceration was located more proximally in the stomach (Lilja l959; Burge et al. l963; du Plessis l963; Schrager et al. l967; Gear et al. l97l; Lawson l972; Meister et al. l979). Some investigators looked upon "antral" gastritis as the primary event (Schrager et al. l967; Gear et al. l97l), while others pointed out that the relationship between gastritis and gastric ulceration remained controversial (Lawson l972; Liebermann-Meffert and Allgöwer 1977).

Narrowing of the pyloric region in cases of chronic, benign gastric ulceration in the region of the angulus has been described by several authors. Steigman (l943) for instance, noted "antral spasm" in a small percentage of cases where the ulcer was located at the incisura angularis. Lilja (l953, l954) found the canalis egestorius (i.e. the pyloric sphincteric cylinder) to be contracted in some of these cases of gastric ulceration. The cylindrical contraction might resemble AHPS, or it might be less severe and be more in the nature of an impairment of motility; irregular and oblique mucosal folds might be present in the contracted region, and the pylorus might be patent. Burge et al. (l963) called the condition the "pyloric channel syndrome", while Schrager et al (l967) termed it "stenosis of the antrum".

Motility disturbances of the pyloric region in cases of gastric ulceration of the corpus were described by Garret et al. (l966) during manometric studies, by Kwong et al. (l970) during myoelectrical investigations and by Miller et al. (l980) in gastric emptying studies.

One case in which AHPS was associated with a gastric ulcer located 6.0cm proximal to the pylorus was described by Skoryna et al. (l959), and another by Knight (l96l) (Chap. 24); the latter author considered AHPS to be the cause of the ulcer. According to Liebermann-Meffert and Allgöwer (l977) nodular or fusiform thickening in the pyloric and prepyloric musculature, with mucosal and submucosal changes, reduction in the number of Auerbach's plexuses and fibrosis, occurred not uncommonly in association with gastric ulceration more proximally in the stomach; these alterations caused a disturbance of normal motility and of the "antral pump mechanism".

The cases described here show that a chronic, benign gastric ulcer, situated away from (i.e. orally to) the pyloric region, may be associated with contraction of the pyloric sphincteric cylinder. In a recent series of 65 consecutive cases of chronic gastric ulceration, where the ulcer was located more proximally in the stomach (usually in the region of the angulus on or near the lesser curvature), we noted a constant contraction of the pyloric sphincteric cylinder in 10. (Comment: Although histology of the ulcer was obtained in all instances, microscopic examination of the pyloric region was not considered to be a routine examination and was not done). This confirms the findings of Lilja (l953, l954), and will probably also explain some of the appearances described by Steigmann (l943), Schrager et al. (l967), and others.

Contraction of the pyloric sphincteric cylinder may be associated with increased duodenogastric reflux (Chap. 27), fixation of the pyloric aperture in the "open" position (Chap. 20), decreased cyclical activity (Chap. 20), delayed emptying of solids (Chap. 18) and diminished trituration (Chap. 18). Among the abnormalities encountered in patients with gastric ulceration in the corpus of the stomach, Brooks (l985) mentioned increased bile reflux, incompetent pylorus, reduced amplitude of gastric "antral" contractions and delayed gastric emptying of solids. It appears possible that contraction of the pyloric sphincteric cylinder may be a factor in the pathophysiology of these cases.

Why some cases of ulceration in the gastric corpus should be associated with contraction of the pyloric sphincteric cylinder and others not, is not known. It is not clear whether gastric ulceration or contraction of the cylinder is the primary event. We have not been able to establish a clear relationship between the size, chronicity or exact situation of the ulcer on the one hand, and contraction of the cylinder on the other.

Malignant Gastric Ulcer

Contraction of the pyloric sphincteric cylinder in the presence of an ulcer in the corpus does not necessarily indicate a benign ulcer. During the present investigation the following case, proving the opposite, was encountered.

Case Report

Case 29.4 F.F., 29 year old female, presented with epigastric pain and loss of weight. Radiographic examination showed an ulcer 1.5 cm in diameter on the lesser curvature of the stomach at the incisura angularis (Fig. 29.4 (A-D). A cylindrical contraction, 3.0 cm in length and containing a longitudinal mucosal fold, was seen in the pyloric region; a prominent pseudo-diverticulum was evident on the greater curvature side of the contraction, the appearances tallying with contraction of the pyloric sphincteric cylinder. Occasionally a minor degree of relaxation occurred, but most of the time the contraction remained as illustrated, with absence of normal cyclical activity. (Fig. 29.4 A-D). Response to anti-ulcer therapy was poor. Endoscopic biopsy 6 months later showed an ulcer at the angulus with surrounding induration. Microscopically the base of the ulcer consisted of fibrinopurulent material, fibrotic tissue and well-differentiated adenocarcinoma cells. Billroth II partial gastrectomy confirmed the large ulcer with indurated edges on the lesser curvature. Microscopically a well- differentiated adenocarcinoma, infiltrating locally through the muscularis externa into the subserosal tissue, was seen. The adjacent gastric mucosa showed areas of intestinal metaplasia. Microscopic examination of l7 lymph nodes revealed no carcinoma cells. It was concluded that the appearance of a chronic ulcer with dense fibro-collagenous tissue and carcinoma cells in the base, was compatible with so-called "ulcer cancer", i.e. carcinoma originating in a chronic gastric ulcer.

Fig. 29.4 A-D Case F.F. Malignant ulcer at incisura angularis (open arrow). Constant contraction of pyloric sphincteric cylinder with absent cyclical activity (filled arrows)