Chapter 35 (page 177)

The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 35 (page 177)

Chapter 35

Malignancy at the Gastro-Oesophageal Junction

It has been shown that some cases of hiatus hernia are associated with motility disturbances of the pyloric sphincteric cylinder (Chap. 32). In most cases of malignancy at, or in the immediate vicinity of the gastro-oesophageal junction, we have also noted contraction of the pyloric sphincteric cylinder to greater or lesser degree. The malignancy involved either the gastric fornix or the lower oesophagus; in some cases it was difficult to determine (for a variety of reasons) whether the lesion was primarily gastric or primarily oesophageal.

The incidence of contracted pyloric sphincteric cylinder in cases of malignancy at the cardia has not been determined, but it appears if it occurs in the majority of cases. We have become aware of the association only recently; to the best of our knowledge it has not been described previously.

The following are examples of 11 cases which have been encountered:

Case Reports

Case 35.1S.S., 67 year old male, presented with increasing dysphagia. Radiographic examination showed a constant, irregular filling defect of the lower 5.0 to 6.0 cm of the oesophagus, typical of carcinoma; it extended as far as the gastro-oesophageal junction, i.e. through the oesophageal hiatus in the diaphragm (Fig. 35.1D). The pyloric sphincteric cylinder showed a constant contraction, appearing to be "fixed" midway between maximum contraction and maximum dilatation, with absent cyclical activity (Fig. 35.1A-C). Most of the time the pyloric aperture contained barium, i.e. it was patent; at times it contained a single mucosal fold. At oesophagoscopy only the upper border of the carcinoma could be visualized; biopsy was unsuccessful. Repeat radiography a month later showed extension of the oesophageal lesion with only a trickle of barium entering the stomach.

Fig. 35.1. A-DCase S.S. A-C Constant contraction pyloric sphincteric cylinder with absent cyclical activity. D Irregular filling defect lower oesophagus extending through diaphragmatic hiatus, indicating carcinoma.