The Pyloric Sphincteric Cylinder in Health and Disease



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Chapter 38 (page 192)

Case 38.3 M.W., 51 year old male, complained of vague upper abdominal symptoms of 4 months' duration. Clinical examination revealed no abnormality and he was referred for radiological examination. During partial contraction of the pyloric sphincteric cylinder the base of the duodenal bulb showed a shallow, concave indentation (Fig. 38.3A). During maximal contraction of the cylinder an umbrella-like defect was seen in the base of the bulb, with longitudinal mucosal folds in the fully formed pyloric canal (Fig. 38.3B). The case was diagnosed as prolapsed gastric mucosa.

A
B Fig. 38.3 A,B. Case M.W. A Partial contraction of sphincteric cylinder. Shallow, concave indentation base of duodenal bulb. B Case M.W. Maximal contraction of cylinder. Umbrella-like defect base of bulb continuous with longitudinal mucosal folds in pyloric canal

Discussion

Most of the authors quoted agree that normally there is a certain looseness of the mucosa in the pyloric region of the stomach (i.e. presumably in the pyloric sphincteric cylinder). Scott (l946) found that this was not sufficient to allow prolapse of gastric mucosal folds into the duodenum. Manning and Gunter (l950) stated that in patients with marked prolapse of the gastric mucosa the mucosal looseness was exaggerated and the redundant folds could lie either in the pyloric canal (presumably the pyloric aperture), or could easily be drawn through it into the duodenum for variable distances. Keet (l952) confirmed a certain looseness of the mucosa of the sphincteric cylinder in normal, adult, fresh post-mortem specimens. Williams (l962) showed that a minor degree of extrusion of the gastric mucosa through the pyloric aperture, of not more than 3.0 mm, might occur normally during forceful contraction of the "pyloric press" (presumably the pyloric sphincteric cylinder).

Cases verified at surgery and post-mortem leave little doubt that prolapse of gastric mucosa into the duodenum does occur and that the condition should be recognized as a separate entity.

Types and Grades of Prolapse

Circumferential. In the majority of cases transpyloric prolapse of gastric mucosa is of a circumferential nature, in which a whole cuff of gastric mucosa prolapses into the duodenal bulb. This has sometimes been divided into mild (synonyms: minimal, slight, early), moderate and severe grades (Scott 1946; Nygaard and Lewitan 1948; Manning and Gunter 1950).

Linear or Tongue-like. Occasionally 2 or 3 tongue-like processes of gastric mucosa, involving only part of the circumference, extend into the duodenum (Hawley et al. 1949; Manning and Gunter 1950). This appearance may be associated with duodenal ulceration as found in verified cases (Zimmer 1950; Keet 1952). In these cases the typical mushroom-like defect of circumferential prolapse is not evident, but 2 or more longitudinal folds extend through the pyloric aperture, each ending independently in the bulb.

Not infrequently a single gastric mucosal fold is seen to extend through the pyloric aperture into the base of the bulb. This is considered to be a normal appearance (Scott 1946; Bralow and Melamed 1947; Hawley et al. 1949) and may have a phylogenetic basis. Torgersen (1942) found a similar appearance in certain lower vertebrates and considered it to be a functional mucosal "torus" in man.

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