Chapter 39 (page 197)

The Pyloric Sphincteric Cylinder in Health and Disease

Go to chapter: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | 39
Chapter 39 (page 197)

The following cases are examples of acid corrosive injuries:

Case Reports

Case 39.1 L.M., female aged 29 years, accidentally swallowed a cupful of hydrochloric acid. This was followed by burning restrosternal and epigastric pain and continuous vomiting. Radiographic examination a week later revealed no abnormality in the oesophagus. A severe stricture, causing almost total occlusion of the lumen and commencing as a funnel-shaped narrowing in the region of the incisura angularis, was seen in the distal third of the stomach (Fig 39.1). At times a trickle of barium traversed the stricture, which was constant; the sphincteric cylinder and pyloric aperture were unidentifiable, with total absence of cyclical contraction and relaxation. Repeat examination after another week showed similar features, although the stricture appeared to be somewhat less severe. Antrectomy and Billroth I anastomosis 3 weeks after the incident showed the distal 5.0 to 6.0cm of the stomach to be oedematous and stenotic; the duodenum appeared normal. Microscopically severe fibrotic change was seen in the submucosa, with areas of necrosis and partial regeneration in the mucosa.

Fig. 39.1. Case L.M. Funnel-shaped, severe stricture in distal stomach

Case 39.2 D.P., 23 year old male, swallowed half a tumblerful of hydrochloric acid in an attempted suicide. After some hours he was admitted to a peripheral hospital where gastric lavage with dilute alkali was performed. Dysphagia and continuous vomiting necessitated oesophagoscopy after 10 days. This showed mucosal erosions and moderate oesophageal stenosis at 33cm. Upper gastrointestinal barium examination revealed a constant narrowing of the distal third of the stomach with absent cyclical contraction and relaxation of the pyloric sphincteric cylinder (Fig 39.2). This was associated with a patent pylorus and rapid emptying of fluid barium. The entire duodenum showed loss of mucosal pattern with rigid walls; immediately beyond the duodeno-jejunal flexure a 3.0cm long stenotic area was evident.

Fig. 39.2. Case D.P. Constant narrowing distal third of stomach. Pyloric aperture patent. Absent cyclical activity of pyloric sphincteric cylinder. Duodenal walls rigid. Stenosis proximal jejunum

Discussion

As can be expected, the above cases show that acid corrosive injury of the stomach is not contained by anatomical boundaries, and therefore not necessarily limited to the pyloric sphincteric cylinder or to the pyloric mucosal zone. Usually the walls of the cylinder are damaged as part of a more extensive injury; the result is that the pyloric sphincteric cylinder is no longer recognizable as a functional unit. In Case 39.1 the cylinder was almost totally occluded as part of a more extensive stricture, causing obstruction to the flow of fluid barium. In Case 39.2 partial contraction of the cylinder "fixed" the pyloric aperture in the open position, leading to rapid emptying of fluid barium; theoretically the lack of cyclical contraction of the cylinder in this case should hamper trituration (Chap 18) and delay the emptying of solids (Chap 18).

A consequence of corrosive injury of the pyloric mucosal zone is that gastrin producing G-cells in this location may be affected, leading to a histamine-fast achlorhydria. It is probable that cells producing other regulatory peptides, e.g. somatostatin, vasoactive intestinal peptide and enkephalin (Chap 9) will also be damaged.