The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 31 (page 154)

Einhorn et al. (1984) reviewed the literature of acquired double pylorus and reported 4 new cases with long term follow-up. In 36 cases the fistula extended from the lesser curvature of the "antrum" to the superior portion of the duodenal bulb. In 28 of these it had originated from "antral" ulcers, in 2 from "pyloric channel" ulcers and in 6 from duodenal ulcers. In 9 cases the fistula was situated between the greater curvature and the inferior portion of the duodenal bulb, 7 originating from antral ulcers, one from a pyloric channel ulcer and one from a duodenal ulcer. The radiological appearance of a double pylorus was said to be characteristic, consisting of two channels of barium separated by a smooth band of soft tissue which represented the intervening mucosal septum. The endoscopic appearance was also typical, the aperture of the fistula being clearly visible in the majority of cases. With the endoscope in the "distal antrum", it was frequently possible to insert a biopsy instrument into the fistula and visualize its tip within the duodenum by viewing through the pylorus.

None of the cases of acquired double pylorus reported up to 1984 had been associated with malignancy (Einhorn et al. 1984). Friehling and Rosenthal (1985) subsequently described an unusual case of gastric carcinoma in which the radiological appearance of a double-channel pylorus was the result of partition of the pyloric aperture by the tumor, no fistula being present.

The radiological features of two more (unconfirmed) cases of benign, acquired pyloro- duodenal fistula were subsequently described by Hurwitz and Friedman (1987).


Acquired double pylorus or pyloro-duodenal fistula occurring as a result of perforation of a peptic ulcer has also been known by the terms pseudo-pylorus, tunnel ulcer, pyloric diaphragm, antral mucosal band and pyloric septum (Drapkin et al. 1974; Hegedus et al 1978). None of the authors quoted, with the exception of Keet and Bezuidenhout (1984), described the condition in relation to the concept of the pyloric sphincteric cylinder.

Our cases had the following features in common: In all the pyloro-duodenal fistula extended from the superior aspect of the distal part of the pyloric sphincteric cylinder to the superior fornix of the duodenal bulb, i.e. it was situated on the lesser curvature side. (As reported in the literature the fistula may occasionally occur on the greater curvature side).

In all 4 cases the sphincteric cylinder remained partially contracted (or, in other words, incompletely expanded) throughout the radiological examination; although minor degrees of contraction and relaxation did occur, these movements were never maximal. This is best illustrated in Fig. 31.2, in which a permanent contraction of the left pyloric loop on the greater curvature, opposite the commencement of the fistula, is seen. In Case 31.4 the contraction at times reached the pseudo-diverticulum stage (Fig. 31.4B), before reverting to incomplete expansion (Fig. 31.4A).

It is concluded that our cases of acquired pyloro-duodenal fistula were associated with motility disturbance of the pyloric sphincteric cylinder, consisting of a restriction in the range of contraction and relaxation. Theoretically this could have an effect on emptying and trituration of solids (Chap. 18). Emptying of liquid barium occurred without undue delay through both orifices.


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