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Chapter 32 (page 156)
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.
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
n |
Series 2
n |
|
| Sliding hiatus hernia without contracted pyloric segment | 112 | 65 |
| Sliding hiatus hernia with contracted pyloric segment | 16 | 27 |
| Irreducible hiatus hernia without contracted pyloric segment | 3 | 24 |
| Irreducible hiatus hernia with contracted pyloric segment | 2 | 9 |
| Sliding and rolling hiatus hernia with contracted pyloric segment | 1 | 0 |
| Total | 134 | 125 |
| Total hiatus hernia cases without contracted pyloric segment | 115 | 89 |
| Total hiatus hernia cases with contracted pyloric segment | 19 | 36 |
| Per cent hiatus hernia cases with contracted pyloric segment | 14.2 | 28.8 |
|
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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