Chapter 33 (page 165)

The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 33 (page 165)

The following are representative cases:

Case Reports

Case 33.1 A.S., 63 year old male, presented with loss of weight, epigastric pain and haematemesis of one year's duration. Radiology showed a constant, lobulated filling defect 4.0 to 5.0 cm in length in the region of the pyloric sphincteric cylinder; aborally it extended to within one or two millimeters of the pyloric ring (Fig. 33.1). The pyloric aperture remained patent throughout. Mucosal folds were absent in the affected region. There was total absence of cyclical contraction and relaxation of the cylinder, the appearance remaining unchanged. The base of the duodenal bulb appeared normal. Emptying of barium suspension was not delayed to any appreciable extent.

At Billroth II partial gastrectomy an ulcerating malignant tumor measuring 6.0 x 2.5 cm was removed. Microscopy showed a poorly differentiated adenocarcinoma infiltrating into the serosa. The adjacent gastric mucosa showed chronic inflammatory cell infiltration and intestinal metaplasia. Both excision lines as well as the draining lymph glands were free of tumor cells.

Fig. 33.1.Case A.S. Lobulated filling defect in pyloric sphincteric cylinder. Mucosal folds and cyclical activity absent. Pyloric aperture patent. Base of duodenal bulb normal.

Case 33.2 J.B., 65 year old female, presented with a large epigastric mass and left supraclavicular Virchow Trosier lymphadenopathy. Radiology showed a constant, irregular narrowing of the distal 8.0 cm of the stomach, with an intraluminal filling defect extending to the pyloric ring. There was narrowing of the aperture and delayed emptying of barium suspension, indicating partial obstruction of the gastric outlet (Fig. 33.2). Food residues were present in the proximal stomach. Mucosal folds were absent in the affected region. There was total absence of cyclical activity of the pyloric sphincteric cylinder. The lesser curvature side of the base of the duodenal bulb showed a smooth, concave identation, apparently due to external pressure; in other respects the bulb appeared normal.

At laparotomy a large carcinoma of the distal part of the stomach, causing partial obstruction, was found. Aborally the tumor boundary was at the pyloric ring; no duodenal infiltration was noted. There was widespread infiltration in the region of the pancreas, in the gastrohepatic and gastrocolic omenta, as well as lymph gland extension. The tumor proved to be unresectable and a palliative gastro-enterostomy was done. Histology of involved lymph nodes showed a papillary adenocarcinoma.

Fig. 33.2.Case J.B. Irregular narrowing distal stomach with intraluminal filling defect. Mucosal folds and cyclical activity of pyloric sphincteric cylinder absent. Pyloric aperture narrowed. Food residues proximal stomach. Concave indentation base of bulb.

Case 33.3 C.J., 57 year old male, presented with loss of appetite and weight of 3 months' duration. Radiology showed a constant, irregular, constricting filling defect of the distal 5.0 cm of the stomach, with absent mucosal folds. Aborally, it extended as far as the pyloric ring (Fig. 33.3). There was a total absence of cyclical contraction and relaxation of the sphincteric cylinder; emptying of fluid barium was not delayed significantly. The base of the duodenal bulb showed shallow, concave indentations on either side of the pyloric aperture, the appearance being suggestive of external impressions. The duodenal "tail" appeared normal (Chap. 13).

Gastroscopy showed a friable, haemorrhagic, polypoid tumor in the corpus and "antrum" of the stomach; the pylorus and duodenum appeared normal. Endoscopic biopsy revealed a moderate to poorly differentiated adenocarcinoma. At laparotomy the aboral border of the tumor was at the pylorus; macroscopically the duodenum was not involved. On the oral side it extended to just below the gastro-oesophageal junction. The tumor was considered to be unresectable and the abdomen was closed.

Fig. 33.3.Case C.J. Irregular, constricting filling defect distal stomach. Mucosal folds and cyclical activity of sphincteric cylinder absent. Duondenal tail (arrow) normal. Concave indentations base of bulb on either side of pyloric aperture.