The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 38 (page 188)

Chapter 38

Prolapse of Gastric Mucosa into the Duodenum

In 1911 Schmiedin described a case of gastric outlet obstruction in which, at operation, a fold of gastric mucous membrane was found to have acted like a ball-valve at the pylorus. The fold could be pushed into the pyloric aperture. While the pre-operative radiographs demonstrated the fold, they did not show definite evidence of prolapse into the duodenum. At operation the fold was excised, resulting in complete recovery of the patient. This appears to be the first description of a case in which redundant gastric mucosa caused significant symptoms.

Eliason and Wright (l925) described a case of a 56 year old male who was operated on for a suspected benign tumor of the stomach. Before opening the stomach a doughy mass was felt projecting through the dilated pylorus into the duodenum. During palpation the mass slipped into the stomach and could not be pushed back into the duodenum. Gastrostomy showed that the entire mucous membrane of the pyloric region was freely mobile on the underlying muscle coat and that it could be pushed through the pylorus, causing invagination of a complete mucous membrane cuff into the duodenum.

Eliason et al. (l926) described a case of a 61 year old male in which the pre-operative radiographs showed a defect extending through the pylorus into the base of the duodenal bulb. It was thought to be a pedunculated tumor of the stomach but operation revealed redundant gastric mucosal folds extending through the pylorus into the duodenum. In another case, that of a 29 year old male, radiographs showed a similar defect in the base of the duodenal bulb. At operation it was found that the pyloric mucous membrane was freely mobile upon the muscle coat and that it had prolapsed through the pylorus into the duodenum. A healed duodenal ulcer was also present.

These appear to be the first recorded cases of prolapse of gastric mucosa into the duodenum. Since that time additional cases have been reported, and by l952 at least 80 verified and 177 unverified cases had been described in the literature. (Comment: "Unverified" indicates cases diagnosed radiologically but not verified by other means. It is possible that the radiological appearances in some of these cases might have been due to normal anatomical variations). These case reports were collected and analyzed in a thesis in which various aspects of the condition were considered (Keet 1952). Subsequently more cases have been reported (vide infra).

At present there appears to be uncertainty, if not scepticism, about the diagnosis, and a need exists for continued investigation of different aspects of the condition. In particular, it seems necessary to determine to what extent the pyloric mucosa is normally mobile in relation to the underlying layers of the wall, and if it is capable of prolapsing into the duodenum.

Normal Mobility of the Mucosa

Cunningham (1906) pointed out that the mucosa of the stomach is closely bound to the submucosa which, in turn, is loosely attached to the muscularis externa. Forssell (l923, l939) showed that two types of mucosal movements exist: (1) co-ordinated movements of the muscularis externa and the muscularis mucosae, which determine to a large extent the size, shape and position of the macroscopic folds; (2) "mucosal autoplastik", i.e. the inherent ability of the mucosa to move, which accounts for the fine, surface mucosal patterns (Chaps. 2, 13).

Cole (l928) showed that the pyloric valve is normally displaced into the duodenum after death. This normal appearance may be mistaken for prolapse of gastric mucosa, and has to be kept in mind whenever the diagnosis of prolapse has to be considered at autopsy.

Golden (l937) stated that the gastric mucosa was normally freely mobile on the muscular layers. This could readily be demonstrated by the separation of mucosa from muscle wall in the fresh specimen at autopsy, as well as by the projection of the mucous membrane over the edge of the muscle when the living stomach was cut at operation. Scott (l946) confirmed this view, but stated that normally the extent of movement was not sufficient to allow prolapse of gastric mucosa into the duodenum. he found it impossible to pull the gastric mucosa through the pylorus into the duodenum by means of surgical forceps in a series of 126 autopsies in which the stomach was normal. There was one exception, a case of severe cardiovascular disease and myocardial infarction. In this case the gastric mucosal folds could be manipulated into the duodenum comparable to the appearance seen in prolapse of the mucosa at operation.

Bralow and Melamed (l947) examined a number of normal stomachs within three hours post mortem and found that a small amount of gastric mucosa could be pulled through the pylorus, simulating a minor degree of prolapse. Ferguson (l948) concluded from observations at autopsy that the mucosa of the normal stomach was movable relative to the muscularis externa, but in no case sufficiently mobile to allow it to be drawn into the duodenum. Manning and Highsmith (l948) confirmed Golden's observation that the gastric mucosa was freely movable over the muscular coat. Manning and Gunter (l950) concluded that there was a certain looseness of the antral mucosa in the normal. In prolapse it was exaggerated and redundant folds could lie in the pyloric aperture or could easily be drawn through the aperture into the duodenum for variable distances.

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