Chapter 33 (page 166)

The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 33 (page 166)

Case 33.4 A.S., 45 year old male, had nausea, early satiety and loss of weight for the previous 3 months. A hard epigastric mass was present. Radiology showed a constant, irregular, sharply defined filling defect 8.0 cm in length in the distal stomach, with absence of mucosal folds. It extended to the pyloric aperture, which was narrowed and not clearly visible most of the time (Fig. 33.4). Cyclical activity of the pyloric sphincteric cylinder was absent; emptying of fluid barium was delayed. The base of the duodenal bulb showed a deep, concave indentation with constant irregularity, suggestive of duodenal spread of the lesion.

Gastroscopy revealed a diffusely infiltrating, fungating mass in the pyloric region, extending to the pylorus and causing partial obstruction. As a result possible duodenal involvement could not be determined. Endoscopic biopsy showed a poorly differentiated, tubular adenocarcinoma. At laparotomy the tumor was confirmed. Metastases were present in the liver, it was considered to be unresectable, and a palliative gastro-enterostomy was done. The condition of the first part of the duodenum could not be determined precisely.

Fig. 33.4.Case A.S. Irregular filling defect distal stomach. Mucosal folds and cyclical activity of cylinder absent. Pyloric aperture unrecognizable. Concave indentation and irregularity of duodenal bulb.

Case 33.5 R.B., 60 year old female, presented with malaena of 5 months' duration, iron deficiency anaemia and an epigastric mass. Radiology showed a constant, lobulated and constricting filling defect in the distal 8.0 cm of the stomach, extending as far as the pyloric aperture, which remained patent. Emptying of fluid barium was not significantly delayed. Mucosal folds in the affected region and cyclical activity of the pyloric sphincteric cylinder were absent. The base of the duodenal bulb showed a smooth, regular, concave indentation, suggestive of external pressure rather than infiltration of the bulb itself (Fig. 33.5).

Gastroscopy revealed a large ulcerating carcinoma extending to the gastro-oesophageal junction on the lesser curvature. Endoscopic biopsy showed a poorly differentiated papillary adenocarcinoma. At laparotomy a large gastric carcinoma was found; there was infiltration of the transverse colon and gall bladder, with metastases in the liver. It was difficult to evaluate the duodenum precisely. The tumor was considered to be unresectable and palliative gastro-enterostomy was done.

Fig. 33.5.Case R.B. Lobulated and constricting filling defect distal stomach. Mucosal folds and cyclical activity of cylinder absent. Pyloric aperture patent. Smooth, concave indentation base of duodenal bulb.

Case 33.6 S.M., 49 year old male, presented with dyspepsia, loss of weight and postprandial vomiting of 7 months' duration. Radiology showed a constant, irregular narrowing with nodular filling defects in the distal 5.0 to 6.0 cm of the stomach; aborally it extended to the pyloric ring. Mucosal folds were not recognizable in the affected region. There was total absence of cyclical activity of the sphincteric cylinder. Emptying of fluid barium was not significantly delayed. A concave indentation of the base of the duodenal bulb, presumably due to external pressure, was seen (Fig. 33.6). In other respects the bulb appeared normal; the duodenal "tail" was normal.

Gastroscopy showed an infiltrating carcinoma of the "antrum", involving the lesser and greater curvatures and extending to within 8.0 cm of the gastro-oesophageal junction; the pyloric aperture could not be visualized. At Billroth II partial gastrectomy the tumor was removed; it extended to the pylorus but not into the duodenum. The transverse mesocolon was attached to it; there were no lymphatic or liver metastases. Microscopic examination revealed a poorly differentiated adenocarcinoma infiltrating deeply into the muscularis externa. No duodenal extension was seen. Draining lymph glands were normal. The surrounding gastric mucosa showed subacute gastritis.

Fig. 33.6. Case S.M. Irregular narrowing distal stomach. Mucosal folds and cyclical activity of cylinder absent. Pyloric aperture deformed. Concave indentation base of duodenal bulb. Duodenal "tail" (arrow) apparently unaffected.