The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 38 (page 190)

Rees (1937) described another case in which the duodenum was opened first. A soft mass of tissue consisting of a ring of gastric mucosa was seen to project through the pyloric aperture. A similar appearance was seen in a case of Archer and Cooper (1939), where a protrusion of gastric mucosa through the pylorus, viewed from the duodenal side, resembled external haemorrhoids about the anus. In a case of Köhler (1950) the duodenum was also opened first. Initially no sign of prolapse was seen but compressing the prepyloric area caused mucosal folds to escape from the pylorus. In the case of White et al. (1966), a scope inserted through a duodenal incision showed gastric mucosa protruding through the pylorus.

In cases where partial gastrectomy is performed because of prolapse per se, or because of an associated lesion (e.g. gastric or duodenal ulceration), the resection specimen may show large circumferential folds of gastric mucosa which can be manipulated into the duodenum. When such a specimen is placed in formalin, the range of movement of the mucosa becomes progressively less with the passage of time (Keet 1952).

Although the entire circumference of the prepyloric mucosa is usually involved in prolapse of the gastric mucosa, a case of active duodenal ulceration was encountered at surgery in which tongue-like, linear processes of gastric mucosa had prolapsed into the duodenal bulb (Keet 1952).

Gastroscopic Diagnosis

Moersch and Weir (1942) and later Tesler (1947) visualized large tumor-like masses of redundant gastric mucosa projecting into the lumen of the stomach at gastroscopy. However, in their cases the folds did not prolapse into the duodenum. Scott (1946) did not obtain postive recognition of folds of redundant gastric mucosa slipping though the pylorus in his cases. Manning and Highsmith (1948) reported gastroscopic confirmation in one case. Ten of the cases of Hawley et al (1949) were examined gastroscopically, the condition being visualized in 2. At gastroscopy White et al. (1966) visualized large, hyperaemic oedematous prepyloric folds which pushed back into the stomach as the "sphincter" closed, in their case. The mucosa had a granular and inflammatory appearance and oozed fresh blood.

The diagnosis of prolapse of gastric mucosa into the duodenum has been confirmed gastroscopically in a few cases only. The value of gastroscopy was to rule out gastritis and erosions in cases which had been diagnosed radiologically (Scott 1946). Van Noate et al. (1948) believed that failure to recognize the condition at gastroscopy might be due to inflation of the stomach, the distension causing the previously prolapsed mucosa to return to a more normal position.

Radiological Diagnosis

The radiological diagnosis of circumferential prolapse of gastric mucosa into the duodenum depends primarily on the demonstration of a rounded or irregularly lobulated filing defect situated centrally in the base of the duodenal bulb. The defect has been described as circular (Eliason et al. 1926; Rees 1937; Bohrer and Copleman 1938; Zimmer 1950), semicircular (Pendergrass and Andrews 1935), irregularly circular (Eliason et al. 1926; Bohrer and Copleman 1938) or arch-shaped (Köhler 1950). The shape of the defect caused by the extruded or prolapsed gastric mucosal folds has been likened to an umbrella (Rees 1937; Van Noate et al. 1948; Fermin 1950; Köhler 1950; Manning and Gunter 1950), a mushroom (Scott 1946; Bralow and Melamed 1947; Hawley et al. 1949; Fermin 1950) and a cauliflower (Scott 1946; Bralow and Melamed 1947; Nygaard and Lewitan 1948). It should be possible to show that the defect is continuous with gastric rugae stretching from the prepyloric area through the pyloric aperture (Scott 1946; Nygaard and Lewitan 1948; Hawley et al. 1949; Todd and Brennan 1957).

The defect in the base of the bulb is not constant, but varies in size and shape (Scott 1946; Nygaard and Lewitan 1948; Hawley et al 1949; Köhler 1950; Keet 1952). This variation is evident not only at different examinations, but also during different stages of the same examination. Most authors seem to associate this characteristic with the position of the patient. It has been frequently stated that the defect is more readily seen with the patient in the horizontal position (Eliason et al. 1926; Rubin 1942; MacKenzie et al. 1946; Manning and Gunter 1950; Zimmer 1950), while others state that it is best seen in the upright position (Köhler 1950). According to some it is equally well seen in the prone and upright positions (Bohrer and Copleman 1938; Scott 1946; Nygaard and Lewitan 1948; Fermin 1950). At times the prolapse may be reduced (Scott 1946) and no defect will be evident (Rees 1937). In our experience the upright position has proved preferable. The duodenal bulb can usually be seen to advantage in this position, and as pointed out by Köhler (1950), the erect posture is the best for a study of peristalsis and for finding a suitable degree of compression. It seems as if the changing nature of the defect may be the result of contractile activity in the distal stomach, rather than changes in the position of the patient.

Bralow and Melamed (1947) thought that mucosal prolapse ensued whenever there was a failure of the normal orad movement of the mucosa during antral systole as described by Golden (1937) (Chap 13). Nygaard and Lewitan (1948) stated that the duodenal defect changed its volume coincident with antral systole and diastole, being more extensive during systole and less obvious in diastole. In the illustrations of one of the cases of Manning and Highsmith (1948) prolapse was only evident during "antral systole". Manning and Gunter (1950) reasoned that inflammatory change in the muscularis mucosae in these cases interfered with its contractility, thus preventing the normal orad movement of the mucosa. Zimmer (1950) noted that changes in the duodenal defect took place during peristaltic activity, and Fermin (1950) stated that prolapse seemed to disappear when gastric peristalsis became less and when the tone of the stomach decreased.

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