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Chapter 29 (page 144)
Golden (l937) pointed out that the narrowing of antral gastritis and spasm, as seen on
radiographs, was confined to that part of the stomach which normally exhibited antral
systole and diastole, i.e. the pyloric sphincteric cylinder (Chap. 28). A similar
contraction could occur in cases of prepyloric ulceration, where the ulcer was surrounded
by contraction of the "fan-shaped muscle". According to Golden (l937) it had been
customary to attribute "antral spasm" in these cases to the ulcer, but as the same spasm
could occur in gastritis without ulceration, it was more likely that the spasm was due to
the inflammatory change in the gastric wall. As pointed out above, an identical
contraction might occur in cases where the ulcer was located more proximally in the
Magnus (l954) examined various features of 421 surgical resection specimens in cases of
gastric ulceration. A total of 131 ulcers were located within 2.5 cm of the pylorus, 50
were situated between 2.5 to 5.0 cm from the pylorus and the remainder were located
further proximally. No morphological difference was found between the ulcers in the
Raffensperger (l955) described an adult case in whom a prepyloric gastric ulcer, situated
on the greater curvature 1.0 cm proximally to the pylorus, was diagnosed radiologically.
Initially no associated narrowing was seen, but as the ulcer healed a prepyloric narrowing
containing prominent irregular mucosal folds, became evident. Five weeks after the
original diagnosis the radiographic appearance of adult hypertrophic pyloric stenosis
(AHPS) was seen, and at operation the gross appearance was that of typical AHPS.
Microscopically the thickening consisted solely of muscular tissue without evidence of
associated oedema or inflammation. A healed gastric ulcer was also present. The
condition was considered to be AHPS which had developed within five weeks around a
healing, prepyloric gastric ulcer.
It has been mentioned that Johnson (l957, l965) and Johnson et al. (l964) divided gastric
ulcers into three types, depending on the associated acid secretory characteristics.
Prepyloric ulcers (occurring within 2.54 cm of the pylorus) and other antral ulcers
(occurring to the right of the angulus but further than 2.54 cm from the pylorus) were
associated with acid hypersecretion, resembled duodenal ulcers clinically, and constituted
Type III gastric ulcers.
Foulk et al. (l957) stated that the "pyloric channel" was not a well-delineated anatomical
entity, and that gastric landmarks and boundaries differed in their details for the
radiologist, the endoscopist, the surgeon and the pathologist (Chap. 2). For that reason
the literature on "pyloric and pyloric-channel" ulcers was confusing. The proximal
boundary of the so-called pyloric channel was difficult to define, and the term merely
described a region of the stomach near the pylorus rather than a definite anatomical
entity. The length of the anatomical pyloric channel was variable, but was approximately
2.0 cm. Pyloric channel ulcers were defined as ulcers occurring between the
gastroduodenal junction and an imaginary line 2.0 cm above the junction; the term
pyloroduodenal ulcers was used to indicate ulcers which straddled the junction. These
authors studied three groups of patients with surgically treated peptic ulcer near the
pylorus. There were 35 cases with pyloric channel ulcers, 29 with pyloroduodenal and l9
with duodenal ulcers. Clinically there were no features which permitted a differentiation
of pyloric channel ulcers from the other two groups.
In their description of 6 cases of AHPS, Skoryna et al. (l959) included one case in which
an ulcer of the pyloric canal was associated with hypertrophy of the musculature of the
canalis egestorius as described by Torgersen (l942) (Chap. 24).
Texter et al. (l959) also drew attention to the confusion which existed concerning the
terminology of the distal portion of the stomach. These authors looked upon the pyloric
sphincter as the muscular ring surrounding the lumen of the gastroduodenal junction, and
the pyloric channel or pyloric canal as the narrow space encompassed by the ring.
Ulceration of the pyloric channel consequently indicated an ulcer involving the ring.
This concept of pyloric channel ulcers differed from that of Foulk et al. (l957), who
would have termed these pyloroduodenal ulcers. In a clinical study of 67 cases of pyloric
channel ulcers Texter et al. (l959) found that although the symptoms were not
pathognomonic, they differed significantly from those of gastric ulcers occurring
elsewhere in the stomach, and from those of uncomplicated duodenal ulcers.
Burge et al. (l963) described a pyloric channel syndrome occurring in association with
gastric ulceration. The ulcer in these cases could be located either high on the lesser
curvature or in the pyloric channel. Pathologically the pylorus and prepyloric region
showed small round cell infiltration and muscle hypertrophy with fibrous replacement of
muscle cells. These features were apt to cause a narrowing of the pylorus and prepyloric
Murray et al. (l967) described features in 47 patients who underwent operation for pyloric
channel ulcers. (Comment: From the description it is clear that the pyloric
channel was equated with the pyloric aperture). Preoperative radiologic examination was
obtained in 42 of the patients and the diagnosis of pyloric channel disease was confirmed
in 41. There was associated duodenal ulcer disease in 25 cases, while 8 patients had an
associated lesser curvature gastric ulcer and 10 associated hiatus hernia. Clinically
pyloric channel ulcer was frequently associated with a symptom complex called the
pyloric syndrome. Dysfunction of the "antral" evacuation mechanism was noted in one
half of the patients. The ulcer was usually associated with low gastric acidity, and
histologically it appeared to occur in gastric mucous membrane.
Gear et al. (l97l) found gastritis associated with prepyloric ulcers to be much less severe,
and also less extensive, than that associated with ulcers in the body of the stomach. In
both groups of ulcers the gastritis occurred predominantly in the distal part of the
stomach and along the middle of the lesser curvature. Superficial or atrophic gastritis
was found to persist or even worsen after healing of the ulcer, whether the treatment was
medical or surgical.
Liebermann-Meffert and Allgöwer (l977, l98l), in their study of surgical resection
specimens, found that the changes in the antropyloric wall occurring in association with
pyloric ulceration, were similar to those seen in gastric ulceration elsewhere in the
stomach (see above); these included abnormalities of Auerbach's plexuses and the
muscularis externa with replacement of contractile muscular tissue by fibrous tissue. It
was thought that this might impair antropyloric motor function.
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