The Pyloric Sphincteric Cylinder in Health and Disease



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Chapter 37 (page 187)

Discussion

The above patients all had symptoms and signs warranting the clinical diagnosis of diabetic gastroparesis. Radiological studies in all showed absent cyclical activity of the pyloric sphincteric cylinder. It has been shown that normal motility of the sphincteric cylinder consists of alternating cycles of contraction and relaxation, occurring at a rte of approximately 3 per minute (Chap. 13); in diabetic gastroparesis these cycles are absent, the cylinder remaining in a state of permanent, partial contraction. As a maximal or complete contraction of the cylinder does not occur, there is a failure of muscular closure of the pyloric aperture (Chap. 13), which remains patent.

The patulous pylorus allows continuous emptying of fluid barium (Case 37.3). Emptying of solid food residues is retarded (Cases 37.1 and 37.2) due to failure of normal cyclical contraction of the sphincteric cylinder, i.e. failure of the normal mechanism of propulsion of solids. The retention of solid tablets with a diameter of 8.0 mm (Case 37.2) indicates failure of trituration of these tablets.

These conclusions tally with some of those of previous authors, and especially with those of Malagelada et al. (l980) and Camilleri and Malagelada (l984). However, we believe that the "antral" motor dysfunction mentioned by them as well as by Achem-Karam etal (l985) and others, can be placed on a firm anatomical footing if reference is made to the findings of Cunningham (l906), Forssell (l913) and Torgersen (l942) (Chap. 3).

The sustained contraction of the pyloric sphincteric cylinder seen radiologically in diabetic gastroparesis will also explain the "peculiar continuous 3 minute antral contractile activity" found by Camilleri and Malagelada (l984) during manometric studies in some of their patients. One agrees with these authors that the disorder is not invariably of a paretic type; in fact, there appears to be hypomotility due to a spastic or hypertonic condition of the gastric smooth musculature, and in particular of the pyloric sphincteric cylinder.

References

  1. Achem-Karam SR, Funakoshi A, Vinik AI, et al. Plasma motilin concentration and interdigestive motor complex in diabetic gastroparesis: effect of metoclopramide. Gastroenterology l985, 88, 492-499.
  2. Camilleri M, Malagelada JR. Gastric motility in disease. In: Gastric and Gastroduodenal Motility, ed Akkermans LMA, Johnson AG, Read NW. Praeger Publ, New York l984, pp 213-214.
  3. Camilleri M, Malagelada JR. Abnormal intestinal motility in diabetics with the gastroparesis syndrome. Eur J Clin Invest l984, 14, 420-427.
  4. Campbell IW, Heading RC, Tothill P, et al. Gastric emptyin in diabetic autonomic neuropathy. Gut l977, l8, 462-467.
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  10. Forssell G, Über die Beziehung der Röntgenbilder des menschlichen Magens zu seinem anatomischen Bau. Fortschr Geb Röntgenstr 1913, Suppl 30, 1-265.
  11. Goyal RK, Spiro HM. Gastrointestinal manifestations of diabetes mellitus. Med Clin North Amer 1971, 55, 1031-1044.
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  13. Horowitz M, Maddox A, Harding PE, et al. Effect of cisapride on gastric and oesophageal emptying in insulin-dependent diabetes mellitus. Gastroenterology l987, 92, 1899-1907.
  14. Kassander P. Asymptomatic gastric retention in diabetics (gastroparesis diabeticorum). Ann Int Med l958, 48, 797-812.
  15. Malagelada JR, Rees WDW, Mazzotta LJ, et al. Gastric motor abnormalities in diabetic and postvagotomy gastroparesis: effect of metoclopramide and bethanecol. Gastroenterology l980, 78, 286-293.
  16. Marshak RH, Maklansky D. Diabetic gastropathy. Amer J Dig Dis l964, 9, 366-370.
  17. Rundles RW. Diabetic neuropathy: general review with report of 125 cases. Medicine l945, 24, 111-160.
  18. Scarpello JHB, Barber DC, Hague RV, et al. Gastric emptying of solid meals in diabetics. Brit Med J l976, 2, 671-673.
  19. Torgersen J. The muscular build and movements of the stomach and duodenal bulb. Acta Rad l942, Suppl 45, 1-191.
  20. Varis K. Diabetic gastroparesis (a review). Scand J Gastroenterol l989, 24, 897-903.
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  22. Yoshida MM, Schuffler MD, Sumi SM. There are no morphologic abnormalities of the gastric wall or abdominal vagus in patients with diabetic gastroparesis. Gastroenterology l988, 94, 907-910.
  23. Zitomer BR, Gramm HF, Kozak GP. Gastric neuropathy in diabetes mellitus: clinical and radiologic observations. Metabolism l968, l7, 199-211.


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