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Chapter 35 (page 177)
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 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.
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