Chapter 32 (page 158)

The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 32 (page 158)

Case 32.4. C.W., 70 year old female, was a known case of hiatus hernia and peptic oesophagitis. Radiographic examination showed irregular narrowing of the distal oesophagus, a sliding hiatus hernia and free gastro-oesophageal reflux (Fig. 32.4A). There was constant contraction of the pyloric sphincteric cylinder, with absence of cyclical activity; the partially contracted cylinder fixed the pyloric aperture in the open position (Fig. 32.4B). Intramuscular administration of an antispasmodic produced no change. Endoscopy confirmed the hiatus hernia with chronic, non-specific oesophagitis. No structural abnormality was seen in the remainder of the stomach, the pyloric region and duodenum.

A B

Fig. 32.4 A. Case C.W. Sliding hiatus hernia with free gastro-oesophageal reflux (arrow). B. Case C.W. Constant contraction of pyloric sphincteric cylinder. Pyloric aperture "fixed" in open position

Case 32.5. N.M., female aged 64 years. Radiographic examination showed a sliding hiatus hernia (Fig. 32.5A), with free and persistent gastro-oesophageal reflux at times. There was a constantly contracted pyloric segment, 4.0 cm in length, corresponding to contraction of the pyloric sphincteric cylinder (Fig. 32.5B). At operation the hernia was repaired via an abdominal route. Palpation of the exposed stomach was equivocal, the surgeon being uncertain whether the pyloric musculature was spastic or thickened, or not. The stomach was not opened. Symptoms suggestive of partial small bowel obstruction appeared a few weeks after the operation. At a second operation 4 months after the first, small bowel adhesions, which had caused the partial obstruction, were severed. At this operation a vagotomy and pyloroplasty were also found necessary.

Fig. 32.5 A. Case N.M. Sliding hiatus hernia (arrow)

Fig. 32.5 B. Case N.M. Constant contraction of pyloric sphincteric cylinder

Comment: Where there is a contracted pyloric segment in the presence of an hiatus hernia, care should be taken to exclude a local organic lesion at the pylorus before the diagnosis of benign contracted segment or pseudohypertrophic pyloric stenosis is made. The following case is an example:

Case 32.6. J.L., female aged 58 years. A sliding hiatus hernia was demonstrated in the Trendelenburg position (Fig. 32.6A). A constant, somewhat irregular narrowing 5.0 cm in length, was present in the pyloric region, simulating contraction of the sphincteric cylinder (Fig. 32.6B). It contained a small filling defect in its oral side. A diagnosis of carcinoma of the pylorus was made and confirmed at laparotomy.

A

Fig. 32.6 A-C. Case J.L. A Sliding hiatus hernia (arrow) with reflux and oesophageal spasm and fibrosis. B,C Narrowed pyloric region with irregular walls and small filling defect. Case of pyloric carcinoma

A	B
`Fig. 32.4 A. Case C.W. Sliding hiatus hernia with free gastro-oesophageal reflux (arrow). B. Case C.W. Constant contraction of pyloric sphincteric cylinder. Pyloric aperture "fixed" in open position`

A
	`Fig. 32.6 A-C. Case J.L. A Sliding hiatus hernia (arrow) with reflux and oesophageal spasm and fibrosis. B,C Narrowed pyloric region with irregular walls and small filling defect. Case of pyloric carcinoma`