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Chapter 33 (page 168)
Radiographic Appearance of Duodenal Bulb
Radiographically the base of the duodenal bulb, as well as its other walls and lumen
appeared normal in 40 of 50 cases of pyloric carcinoma, showing no evidence of tumor
extension (Fig. 33.1). In 2 of the remaining 10 cases a concave, smooth indentation of
the base of the bulb, without other signs of duodenal involvement, was seen (Fig. 33.5).
In 2 cases smaller, concave indentations of the base of the bulb on either side of the
pyloric aperture were noted (Fig. 33.3). Between these indentations a small, triangular
projection of barium extended into the aboral side of the pyloric aperture; this we have
called the duodenal "tail" (Chap. 13). There was a suggestion of infiltration of the base
of the duodenal bulb in 2 of the 10 cases. In the remaining 4 cases the bulb was not
visualized adequately owing to technical factors (e.g. overlying partially obstructed
stomach) and possible duodenal extension could not be determined.
Incidence of Duodenal Spread as Determined at Operation
An attempt was made to determine duodenal involvement or non-involvement by inspection and palpation
in 44 cases at operation. In 9 it was not possible to evaluate the pyloro-duodenal junction
adequately on account of the tumor mass itself, infiltration of surrounding structures,
liver metastases and/or ascites (Table 33.2); these cases were exluded. In other words, 35
cases could be evaluated.
|Type and number of operations||Cases without macroscopic duodenal involvement
||Cases with macroscopic involvement||Unevaluated|
In 23 evaluated Billroth II partial gastrectomies there was no evidence of macroscopic
duodenal spread in 20; duodenal involvement was thought to be present in 3. In 2
Billroth I partial gastrectomies and 2 exploratory laparotomies no duodenal extension
was evident. In 8 evaluated palliative gastroenterostomies the duodenum appeared to be
uninvolved in 6 cases and duodenal extension was noted in 2. In other words,
macroscopic duodenal spread was thought to be present in 5 of 35 cases evaluated at
operation. (Histology subsequently disproved duodenal spread in one of the 5 cases; in
the 2 cases with gastroenterostomies spread was not confirmed owing to lack of
histological examination. In 3 of the 30 cases in which the duodenum appeared normal at
operation, histology did show duodenal spread). It is confirmed that at operation the
duodenum may appear normal macroscopically, in the presence of microscopic evidence
of transpyloric spread of pyloric adenocarcinoma.
Incidence and Extent of Duodenal Spread as seen Microscopically
Histological examination was obtained in 23 resection specimens. Of these 16 showed
no evidence of duodenal extension. In 7 cases duodenal spread of pyloric carcinoma was
seen microscopically; these will be described briefly.
Case 33.8 J.P., 39 year old male. Radiology: 5.0cm long constricting pyloric filling
defect. Smooth, concave indentation base of duodenal bulb (Fig. 33.8). Operation:
Entire lesser curvature of stomach, part of greater curvature and pyloric region infiltrated.
Serosal spread, lymph node and probable liver metastases. Duodenum appears normal.
Billroth II. Gastric histology: well differentiated adenocarcinoma with widespread
infiltration of gastric submucosa and mucosa. Duodenal histology: spread into
submucosa and to lesser extent into mucosa of proximal 2.0 cm of duodenum.
|Fig. 33.8 A-D. Case J.P. Constricting pyloric filling defect.
Smooth, concave indentation base of duodenal bulb.
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