Chapter 29 (page 146)

The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 29 (page 146)

Case 29.7 A.J., 35 year old female, complained of intermittent epigastric pain and postprandial nausea of 5 years' duration. Radiographic examination showed an active ulcer niche on the lower lesser curvature at the commencement of the pyloric sphincteric cylinder (Fig. 29.7). Prominent oblique mucosal folds were drawn in toward the ulcer; (they may also be described as radiating fan-like from the ulcer). The sphincteric cylinder between the ulcer and the pyloric aperture was deformed, filled poorly, contained prominent oblique mucosal folds, and remained unchanging in appearance with absent cyclical activity. The mucosal folds remained fixed in the same position, showing no macroscopic movements. The duodenal bulb filled poorly. Endoscopic biopsy the same month showed a chronic, active ulcer in the prepyloric region without evidence of malignancy. The duodenum was normal. The gastric mucosa in the vicinity of the ulcer showed acute inflammatory cells in the lamina propria with areas of fibrosis and intestinal metaplasia, diagnosed as acute on chronic gastritis. Anti-ulcer therapy was commenced; the patient failed to return for follow-up.

Fig. 29.7. Case A.J. Ulcer (arrow) in sphincteric cylinder, which is deformed. Absent cyclical activity. Prominent, unchanging, oblique mucosal folds drawn in towards ulcer

Case 29.8 L.J., 56 year old female, had a long history of dyspepsia and nocturnal epigastric pain. Radiographic examination showed a constant contraction of the pyloric sphincteric cylinder, the contracted region being approximately 2.0cm in length, with absence of normal cyclical contractile activity (Fig. 29.8). A constant niche on the greater curvature side of the contracted cylinder indicated an active ulcer. The pyloric aperture was "fixed" in the open position and rapid emptying of fluid barium occurred. Anti-ulcer therapy resulted in symptomatic improvement. Endoscopic biopsy a month later showed two active ulcers in the pyloric region, without macroscopic evidence of malignancy. Biopsy was difficult on account of narrowing, only fibrino-purulent material being obtained. Repeat endoscopy after 4 months showed healing of both ulcers; further endoscopy showed no residual ulceration, narrowing or other abnormality.

Fig. 29.8. Case L.J. Constant contraction of pyloric sphincteric cylinder (filled arrows). Ulcer in contracted cylinder (open arrow)

Discussion

The great majority, if not all, cases of chronic, benign ulcers in the pyloric sphincteric cylinder are associated with contraction of the cylinder. In a recent series of 20 consecutive cases of gastric ulceration within 3.0 to 4.0 cm of the pyloric aperture, we noted contraction of the cylinder in all. The degree of contraction may vary from moderate (Fig. 29.5) to severe (Fig. 29.8), and will have a bearing on the radiographic appearance. Contraction of the cylinder implies diminished or absent cyclical activity of its musculature (Chap. 13) which, in turn, may delay emptying of solids and hamper trituration (Chap.18). In some cases contraction is associated with deformity of the cylinder (Fig. 29.6, 29.7). Cyclical activity is absent in these cases as well.

Normally mucosal folds lie in a circular or spiral direction in the distended pyloric sphincteric cylinder, changing to longitudinal when the cylinder contracts (Chap. 13). (This is one of the best examples of co-ordinated movements of the muscularis externa and mucosa originally described by Forssell) (Chap. 13). As movements of the cylinder are diminished or absent in cases of local gastric ulceration, it is to be expected that mucosal fold movements will also be curtailed or absent. In addition some ulcers within the cylinder are associated with an "indrawing" and fixation of mucosal folds (Fig. 29.6, 29.7), further hampering their movements. It is surmized that the impeded or curtailed mucosal fold movements seen in cases of gastric ulceration within the cylinder, may further hamper the processes of expulsion and trituration.

It has been said that the acid-secretory characteristics of pyloric and duodenal ulcers are similar (Johnson l957, l966; Stadelmann et al. l97l; Brooks l985). The present findings show that there are important differences between ulcers within the pyloric sphincteric cylinder on the one hand, and duodenal ulcers (Chap. 30) on the other hand, as far as motility patterns of the cylinder are concerned.