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Chapter 30 (page 148)
Duodenal Ulceration and the Pyloric Sphincteric Cylinder
As far as we are aware the contractile behaviour of the pyloric sphincteric cylinder in
cases of duodenal ulceration has not been described. However, other features of the
pyloric part of the stomach in duodenal ulceration have been studied extensively, and a
consideration of some of these may give an indication of the type of motility which can
Griffith et al. (l966) examined the rate of gastric emptying in a small number of cases of
uncomplicated duodenal ulceration by means of radio-isotope labelled solid meals, and
found it to be faster than normal. Buckler (l967), in a study of 193 patients with
uncomplicated duodenal ulcer, found no significant difference in the total emptying time
of a solid meal as compared with normal subjects, and concluded that the pattern of
gastric emptying in duodenal ulcer patients was similar to that of normal individuals.
Schrager et al. (l967) performed histological examinations of the "antrum" in 75 surgical
resection specimens of duodenal ulceration. In a third of the cases the duodenal ulcer
was adjacent to the pyloric mucosa, and in the remainder it was 2.0 cm distal to the
"sphincter". The duodenal mucosa surrounding the ulcer was normal. In all cases mild,
diffuse inflammatory alterations, involving the whole of the antral mucosa, were noted;
these consisted of lymphocytic and plasma cell infiltration, with variable degrees of
pyloric gland destruction and intestinalization. In the great majority of cases less than 25
percent of pyloric glands were damaged; in a small minority there was a 25 to 50 percent
reduction in glands, and in some of these an increase in fibrous tissue in the submucosa
was observed. The changes were more severe along the lesser curvature near the
boundary zone between the "antral" and body mucosa, i.e. the part furthest removed from
the ulcer; the body mucosa appeared completely normal. It was concluded that duodenal
ulceration was associated with mild inflammatory change of the gastric antral mucosa, in
contrast to gastric ulceration, which was accompanied by much more severe
Griffith et al. (l968), in a second series of cases, again found the gastric emptying rate of
solids to be more rapid in duodenal ulceration than in normal controls, while George
(l968) found that the mean emptying time of a fluid test-meal in 34 patients with
uncomplicated duodenal ulcer did not differ from that of controls.
Kwong et al. (l970) studied the electrical activity of the distal 6.0 cm of the "antrum" by
means of serosal electrodes implanted at operation for duodenal ulceration. The general
patterns of the wave forms, the amplitude of the waves and the conduction time of the
electrical impulses were the same as in normal controls. However, the frequency of the
waves was increased, being approximately 6 cycles per minute in duodenal ulcer as
opposed to 3 cycles per minute in controls. Cobb et al. (l97l), in a study of 12 duodenal
ulcer patients and normal controls, found no difference in the pattern of gastric emptying
of liquids in the two groups.
Fordtran and Walsh (l973) studied gastric emptying of solid meals in 7 patients with
duodenal ulcer and 6 normal subjects. Using an infusion of sodiumbicarbonate to control
intragastric pH and to act as a buffer, it was found that the duodenal ulcer patients
emptied the meal buffer at a much more rapid rate than normal controls. It was
acknowledged that the emptying rate of the buffer might not necessarily be the same as
the emptying rate of the total mass in the stomach.
Using a solid meal labelled with Indium 113m DPTA, Howlett et al. (l976)
compared gastric emptying in 27 duodenal ulcer patients with 26 normal subjects. The
half emptying time did not differ significantly in the two groups; when applying a
method of principal component analysis to the results, a number of duodenal ulcer
patients showed a relative slowing of the rate during the later phase of gastric emptying.
It was suggested that the faster emptying previously found by Griffith et al. (l966, l968)
and by Fordtran and Walsh (l973) might have been due to the fact that their meals had
twice the volume of that of Howlett et al. (l976).
Liebermann-Meffert et al. (l98l) studied the response of gastric musculature to electrical
vagal stimulation during intraoperative vagomotor tests in different groups of patients.
Although a pressure rise occurred in all groups, it was found that the amplitude and
duration of the contractions, and the integrated motor response was significantly greater
in patients with gastric ulcer than in patients with duodenal ulcer. It was concluded that
the motility disorder of the gastric musculature in duodenal ulceration was less evident
than in gastric ulceration and seemed to be of minor importance. During histological
studies of the antropyloric wall in peptic ulcer disease, Liebermann-Meffert and
Allgöwer (l98l) found that less thickening occurred in duodenal ulcer than in
gastric ulcer; the abnormal features of muscle and ganglion cells were also less severe in
Lam et al. (l982), using a marker-dilution method, found that duodenal ulcer patients
emptied liquid meals more rapidly than normal subjects.
Earlam et al. (l985) found histological evidence of chronic "antral" gastritis in 33 of 36
patients with duodenal ulceration who required surgery after prolonged but unsuccessful
medical therapy. Of these, 24 had chronic superficial, and 9 chronic atrophic gastritis.
The high incidence of antral gastritis was considered to be a striking finding; it was
thought that it could be related to the severe symptoms in this particular group of cases.
According to Brooks (l985) duodenal ulceration should be looked upon as a
heterogeneous syndrome which includes the following: (1) acute erosions; (2)
uncomplicated ulcers; (3) bleeding; (4) perforation; (5) gastric outlet obstruction; (6)
ulcers resistant to healing under treatment, and (7) recurrent ulceration after surgery. Not
all patients will exhibit the same abnormalities in function; in some, gastric motor
function may show an increase in frequency and amplitude of "antral" contractions with
accelerated emptying of solids. On the whole associated gastritis of antral mucosa is a
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