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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).
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.
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
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