The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 32 (page 156)

Hiatus Hernia in Adults

Wieser et al. (l963), describing the radiographic appearances of adult hypertrophic pyloric stenosis (AHPS), noted that a fifth of their 44 patients with pyloric hypertrophy also had hiatus hernia (Chap. 24).

Burge (l964) found a high incidence of "pyloric channel disease" in cases of hiatus hernia. The pyloric pathology in these cases consisted of pyloric and prepyloric muscle hypertrophy, mucosal stenosis and external scarring, in varying combinations. Some had previous ulcers in the immediate vicinity of the pyloric ring. Of 5 cases operated on for hiatus hernia, 2 had pyloric mucosal stenosis and 3 stenosis of the pyloric ring with external scarring (presumably due to previous ulceration.) One of these cases also had considerable prepyloric muscular hypertrophy.

Burge et al. (l966) found that pyloric channel disease was more frequently associated with symptomatic hiatus hernia than duodenal ulceration. It was stated that this benign disease at the pylorus had previously frequently been overlooked, both during the radiological examination and at operation. The pylorus and duodenum were studied in 44 consecutive cases of hiatus hernia subjected to operation. Concomitant duodenal ulceration was present in 22 and pyloric channel disease in 34. (The apparent discrepancy was due to the frequent association of duodenal ulceration and pyloric channel disease in the same patient.) It was reiterated that pyloric channel disease included mucosal stenosis, gastritis, pyloric and prepyloric muscle hypertrophy, and scarring. It is clear that Burge (l964) and Burge et al. (l966) described pathological changes in the pylorus not limited to muscular hypertrophy, and presumably due to previous ulceration in many of the cases. However, pyloric channel disease also occurred without evidence of ulceration, and in those cases there was not only pyloric ring change but also a definite prepyloric component, as shown by a contracted and deformed prepyloric region on radiography, and by muscle hypertrophy at operation. In all these cases a long history of duodenal or pyloric disease almost invariably preceded the symptoms of hiatus hernia. Burge (l964) and Burge et al. (l966) did not refer to the findings of Cunningham (1906) and Torgersen (l942), and it appears that few of their cases of pyloric channel disease would fit into the category of muscular hypertrophy of the pyloric sphincteric cylinder.

Radiographic Studies

Patients and Methods

In a previous study of 134 consecutive adult cases of hiatus hernia, we noted a contracted pyloric region, conforming to contraction of the pyloric sphincteric cylinder, in l9 (Table 32.1) (Keet and Heydenrych l97l). Strict criteria were adhered to in the radiographic diagnosis of hiatus hernia. A sliding hernia was only diagnosed if it could be demonstrated from below the diaphragm, and if it is was associated with free and persistent gastro-oesophageal reflux in the Trendelenburg position. In order to achieve this, the patient was instructed to swallow 6 to 7 mouthfuls of a commercial barium suspension, followed by a swallow of water in the erect position. This served to fill the stomach with contrast medium, while the water cleared the oesophagus. The patient was then placed in the Trendelenburg position, and various manoeuvres were done in an effort to demonstrate a sliding hernia. An irreducible hiatus hernia was diagnosed if it was obvious that a part of the stomach was situated permanently above the diaphragm in both the erect and Trendelenburg positions.

Table 32.1. Contracted Pyloric Segment in Hiatus Hernia

Series 1
Series 2

Sliding hiatus hernia without contracted pyloric segment11265
Sliding hiatus hernia with contracted pyloric segment1627
Irreducible hiatus hernia without contracted pyloric segment324
Irreducible hiatus hernia with contracted pyloric segment29
Sliding and rolling hiatus hernia with contracted pyloric segment10
Total hiatus hernia cases without contracted pyloric segment11589
Total hiatus hernia cases with contracted pyloric segment1936
Per cent hiatus hernia cases with contracted pyloric segment14.228.8

In all cases gastric peristaltic waves and contractions of the pyloric sphincteric cylinder were carefully observed radiographically. Normal cyclical contractions of the cylinder (Chap. 13) were evident in 112 cases of sliding, and in 3 cases of irreducible hiatus hernia. Contraction of the pyloric sphincteric cylinder was diagnosed if this region failed to relax fully during the examination, which implied markedly diminished or absent cyclical activity. This was seen in 16 cases of sliding hiatus hernia, in 2 of irreducible hiatus hernia and in one where the hernia was of a combined sliding and rolling type. In these cases contraction of the cylinder ranged from what can be described as moderate (Fig. 32.5B), to severe (Fig. 32.2B) grades; perhaps more important is the fact that in all, the range and/or frequency of cyclical contraction and relaxation of the cylinder was severely curtailed.

More recently we examined a second series of 125 cases of hiatus hernia. Permanent contraction of the pyloric sphincteric cylinder, to greater or lesser degree, was present in 36 (28 percent). There were 92 cases of sliding hernia, 27 showing a contracted cylinder, and 33 cases of irreducible hiatus hernia, 9 with a contracted cylinder (Table I). Comparison of the two series of cases shows that the total percentage of cases of hiatus hernia with a contracted pyloric sphincteric cylinder, has almost doubled in the second series. The reason for this is not clear, but it is presumed that only the more severe grades of contraction were included in the first series.

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