Chapter 33 (page 167)

The Pyloric Sphincteric Cylinder in Health and Disease

Go to chapter: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | 39
Chapter 33 (page 167)

Case 33.7 M.B., 68 year old female, presented with a large, hard epigastric mass. Radiology showed a constant narrowing of the distal 3.0 to 4.0 cm of the stomach, somewhat resembling partial contraction or spasm of the pyloric sphincteric cylinder (Fig. 33.7A). However, it contained a filling defect and mucosal folds were absent. While some degree of movement was seen, this was atypical, with total absence of cylical contraction and relaxation of the cylinder (Fig. 33.7B - E). The base of the duodenal bulb appeared normal. Emptying of barium suspension was not significantly delayed.

At Billroth II partial gastrectomy a large, ulcerated pyloric carcinoma, extending aborally as far as the pyloric ring, was removed. The duodenum appeared normal. Microscopy revealed a signet ring cell carcinoma extending as far as the lamina propria and not involving the muscularis. The duodenum was confirmed to be normal.

Fig. 33.7. A Case M.B. Narrowing distal 3.0 to 4.0 cm of stomach resembling partial contraction or spasm of sphincteric cylinder.

Fig. 33.7 B-E. Case M.B. Filling defect in narrowed region. Mucosal folds absent. Some movement evident but cyclical contraction and relaxation of sphincteric cylinder absent. Base of duodenal bulb appears normal.

Results

Pyloric region

Radiographic Anatomy of Sphincteric Cylinder In all 50 verified cases of pyloric carcinoma, alteration, deformity or destruction of the anatomical constituents of the pyloric sphincteric cylinder occurred to greater or lesser extent. In most cases the cylinder was totally unrecognizable; in 3 an appearance vaguely simulating the normal cylinder was seen (Fig. 33.7A). In some cases the process was of a mainly proliferative type, causing intraluminal filling defects (Fig. 33.1). In others it was mainly infiltrative, causing rigidity of the walls and "fixing" of the pyloric aperture in the patent or open position, with apparently a normal rate of emptying of fluid barium (Fig. 33.5). The process was of a mainly stenosing nature in other cases, with irregularity of the walls and narrowing of the lumen and pyloric aperture, causing partial or total obstruction (Fig. 33.2, 33.6). In many cases the tumor mass was ulcerated; not infrequently a combination of the above appearances was seen. In the few cases where the process somewhat resembled partial contraction of the normal cylinder, associated filling defects, mucosal destruction and atypical, restricted movements confirmed the diagnosis.
Of importance is the fact that the narrowing did not tally with any phase of the normal, cyclical contraction of the sphincteric cylinder. There was destruction of mucosal folds within the confines of the lesion in all cases.

Motility of Sphincteric Cylinder In all cases movements of the pyloric sphincteric cylinder were abolished or markedly altered. Only in 3 cases some movement occurred, but it was atypical (Fig. 33.7B); normal cyclical contraction and relaxation of the cylinder was absent in all.

Emptying of Liquid Barium In most cases there was no appreciable delay in the emptying of barium suspension; in a few cases incomplete or almost complete obstruction to the flow of liquid barium occurred.