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Chapter 29 (page 138)
Chapter 29
Gastric Ulceration and the Pyloric Sphincteric Cylinder
Johnson (l957, 1965) and Johnson et al. (l964) held that gastric ulcers should not only be
classified anatomically according to their distance from the pylorus, but also in
accordance with their associated acid-secretory or patho-physiological characteristics.
While most gastric ulcer patients were acid hyposecretors, some were moderate and
others hypersecretors of acid. On this basis the following 3 types of gastric ulcers were
recognized: Type I consisted of those cases in whom the ulcer was situated to the left of
and above the gastric angulus (the angulus being defined as the lowest point of the lesser
curvature), without macroscopic abnormalities of the prepyloric region, the pylorus or
duodenum; these cases were associated with a low level of acid secretion and possibly
hyposecretion of mucus. Type II consisted of those cases in which a gastric ulcer to the
left of the angulus was associated with, and probably secondary to, an ulcer or its scar in
the pylorus or duodenum; these patients were moderate and sometimes hypersecretors of
acid. Type III included all gastric ulcers on or near the pylorus, and might be combined
with a duodenal ulcer or a Type II gastric ulcer proximally; these patients usually had
hypersecretion of acid. Type III was subdivided as follows: (1) ulcers within one inch
(2.54 cm) of the pylorus, called true prepyloric ulcers; (2) ulcers to the right of the
angulus but further than 2.54 cm from the pylorus, called "other antral" ulcers. It was
concluded that gastric ulcers near the pylorus and those occurring with a duodenal ulcer
should be looked upon as a disease of acid hypersecretion; in these cases there was a
marked blood group O predominance, the ulcers nearest the pylorus carrying the highest
proportion of blood group O. Gastric ulcers in the body of the stomach, occurring in
patients in whom the duodenum was normal, were usually characterized by acid
hyposecretion; in these patients there was no evidence of group O preponderance, but in
fact an excess of blood group A. The findings showed that the pathogenesis differed in
different types of gastric ulcers.
In their endoscopic studies of the mucosal morphology in 200 patients with chronic
gastric ulceration, Stadelmann et al. (l97l) classified the ulcers according to their
anatomical location, i.e. whether they were situated in the "prepyloric antrum", at the
angulus, in the middle of the body or in the subcardial region. A close relationship
existed between the location of the ulcer and the maximal acid secretion. Ulcers of the
"prepyloric antrum" were similar to duodenal ulcers, having hyperchlorhydria, while
those at the angulus had normochlorhydria and subcardial ulcers had hypochlorhydria. It
was concluded that the maximal acid output decreased the farther the ulcer was away
from the pylorus.
In an extensive review Brooks (l985) divided chronic, benign, recurrent gastric ulcers
into the following subgroups: (1) corpus or fundus ulcers; (2) antral or prepyloric ulcers;
(3) pyloric channel ulcers; (4) a combination of any of the above with duodenal
ulceration; (5) ulcers resistant to healing under treatment.
In view of the fact that the present investigation is primarily concerned with the muscular
anatomy of the stomach and motility, we divided gastric ulcers into 2 types, viz. those
situated proximally to the pyloric sphincteric cylinder and those occurring within the
cylinder, i.e. within 3.0 cm to 4.0 cm of the pyloric aperture.
In a radiological investigation of 200 patients with large, chronic benign gastric ulcers on
the lesser curvature of the pars media, Steigman (l943) found associated "antral spasm"
(which he equated with pylorospasm) in a small percentage of cases. At times the spasm
was persistent and quite marked, the whole "antrum" distal to the ulcer being contracted
throughout the examination. (Comment: On accompanying illustrations it
appears if the "antral spasm" is limited to the pyloric sphincteric cylinder).
Lilja (l953, l954) pointed out that in cases of ulceration at the incisura angularis,
associated changes in the pyloric part of the stomach were not unknown but had not been
subjected to a systematic analysis. In his radiological investigations Lilja found that
gross ulceration at the incisura was usually associated with an impairment of gastric
motility in the distal stomach, consisting of altered peristalsis with dilatation of the sinus.
Of 21 cases with a large ulcer at the incisura, radiological examination showed dilatation
of the sinus in 18; in 4 cases in which the ulcer was smaller, the sinus was not dilated. In
some of these cases the appearance of the canalis egestorius (i.e. the pyloric sphincteric
cylinder) also deviated from the normal, showing a cylindrical contraction in several. In
others it contained irregular and oblique mucosal folds, while its contractions were
atypical and occurred at infrequent intervals. At times there was a non-characteristic
functional impairment of the canalis with the pylorus remaining widely patent.
Histological examination in one of these cases showed chronic inflammatory changes in
the mucosa of the canalis with infiltration of plasma cells and hyperplasia of lymph
follicles. Another case showed follicular and antral gastritis. In all cases destruction of
the muscularis externa, with fibrous replacement, was seen at the site of the ulcer (at the
incisura). Lilja (l953, l954) concluded that in cases of ulceration at the incisura angularis,
associated changes were frequently seen in the canalis egestorius. The most common
appearance was a more or less permanent contraction of the canalis of varying severity,
resembling adult hypertrophic pyloric stenosis (AHPS) in the most pronounced cases.
Lilja (l959) subsequently stated that the changes in the canalis were so common that they
had to be regarded as an inherent part of the radiological appearance in cases of deep
ulceration at the incisura. In some cases it was found that the contraction of the canalis
persisted for periods of 2 to 4 years after healing of the ulcer.
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