30 - Duodenal Ulceration and the Pyloric Sphincteric Cylinder

Duodenal Ulceration and the Pyloric Sphincteric Cylinder #

As far as we are aware the contractile behaviour of the pyloric sphincteric cylinder in cases of duodenal ulceration has not been described. However, other features of the pyloric part of the stomach in duodenal ulceration have been studied extensively, and a consideration of some of these may give an indication of the type of motility which can be expected.

Griffith et al. (l966) examined the rate of gastric emptying in a small number of cases of uncomplicated duodenal ulceration by means of radio-isotope labelled solid meals, and found it to be faster than normal. Buckler (l967), in a study of 193 patients with uncomplicated duodenal ulcer, found no significant difference in the total emptying time of a solid meal as compared with normal subjects, and concluded that the pattern of gastric emptying in duodenal ulcer patients was similar to that of normal individuals.

Schrager et al. (l967) performed histological examinations of the "antrum" in 75 surgical resection specimens of duodenal ulceration. In a third of the cases the duodenal ulcer was adjacent to the pyloric mucosa, and in the remainder it was 2.0 cm distal to the "sphincter". The duodenal mucosa surrounding the ulcer was normal. In all cases mild, diffuse inflammatory alterations, involving the whole of the antral mucosa, were noted; these consisted of lymphocytic and plasma cell infiltration, with variable degrees of pyloric gland destruction and intestinalization. In the great majority of cases less than 25 percent of pyloric glands were damaged; in a small minority there was a 25 to 50 percent reduction in glands, and in some of these an increase in fibrous tissue in the submucosa was observed. The changes were more severe along the lesser curvature near the boundary zone between the "antral" and body mucosa, i.e. the part furthest removed from the ulcer; the body mucosa appeared completely normal. It was concluded that duodenal ulceration was associated with mild inflammatory change of the gastric antral mucosa, in contrast to gastric ulceration, which was accompanied by much more severe inflammatory alterations.

Griffith et al. (l968), in a second series of cases, again found the gastric emptying rate of solids to be more rapid in duodenal ulceration than in normal controls, while George (l968) found that the mean emptying time of a fluid test-meal in 34 patients with uncomplicated duodenal ulcer did not differ from that of controls.

Kwong et al. (l970) studied the electrical activity of the distal 6.0 cm of the "antrum" by means of serosal electrodes implanted at operation for duodenal ulceration. The general patterns of the wave forms, the amplitude of the waves and the conduction time of the electrical impulses were the same as in normal controls. However, the frequency of the waves was increased, being approximately 6 cycles per minute in duodenal ulcer as opposed to 3 cycles per minute in controls. Cobb et al. (l97l), in a study of 12 duodenal ulcer patients and normal controls, found no difference in the pattern of gastric emptying of liquids in the two groups.

Fordtran and Walsh (l973) studied gastric emptying of solid meals in 7 patients with duodenal ulcer and 6 normal subjects. Using an infusion of sodiumbicarbonate to control intragastric pH and to act as a buffer, it was found that the duodenal ulcer patients emptied the meal buffer at a much more rapid rate than normal controls. It was acknowledged that the emptying rate of the buffer might not necessarily be the same as the emptying rate of the total mass in the stomach.

Using a solid meal labelled with Indium 113m DPTA, Howlett et al. (l976) compared gastric emptying in 27 duodenal ulcer patients with 26 normal subjects. The half emptying time did not differ significantly in the two groups; when applying a method of principal component analysis to the results, a number of duodenal ulcer patients showed a relative slowing of the rate during the later phase of gastric emptying. It was suggested that the faster emptying previously found by Griffith et al. (l966, l968) and by Fordtran and Walsh (l973) might have been due to the fact that their meals had twice the volume of that of Howlett et al. (l976).

Liebermann-Meffert et al. (l98l) studied the response of gastric musculature to electrical vagal stimulation during intraoperative vagomotor tests in different groups of patients. Although a pressure rise occurred in all groups, it was found that the amplitude and duration of the contractions, and the integrated motor response was significantly greater in patients with gastric ulcer than in patients with duodenal ulcer. It was concluded that the motility disorder of the gastric musculature in duodenal ulceration was less evident than in gastric ulceration and seemed to be of minor importance. During histological studies of the antropyloric wall in peptic ulcer disease, Liebermann-Meffert and Allgöwer (l98l) found that less thickening occurred in duodenal ulcer than in gastric ulcer; the abnormal features of muscle and ganglion cells were also less severe in duodenal ulceration.

Lam et al. (l982), using a marker-dilution method, found that duodenal ulcer patients emptied liquid meals more rapidly than normal subjects.

Earlam et al. (l985) found histological evidence of chronic "antral" gastritis in 33 of 36 patients with duodenal ulceration who required surgery after prolonged but unsuccessful medical therapy. Of these, 24 had chronic superficial, and 9 chronic atrophic gastritis. The high incidence of antral gastritis was considered to be a striking finding; it was thought that it could be related to the severe symptoms in this particular group of cases.

According to Brooks (l985) duodenal ulceration should be looked upon as a heterogeneous syndrome which includes the following: (1) acute erosions; (2) uncomplicated ulcers; (3) bleeding; (4) perforation; (5) gastric outlet obstruction; (6) ulcers resistant to healing under treatment, and (7) recurrent ulceration after surgery. Not all patients will exhibit the same abnormalities in function; in some, gastric motor function may show an increase in frequency and amplitude of "antral" contractions with accelerated emptying of solids. On the whole associated gastritis of antral mucosa is a common finding. Holt et al. (l986) pointed out that gastric emptying rate measurements in patients with duodenal ulcer had produced conflicting results. Many previous studies had failed to identify any gastric emptying abnormality, while in others the rate was found to be faster than in normal controls. The conflicting results might have been due to factors such as differences in experimental methods and differences in meal composition; the exact stage at which emptying was measured in relation to the treatment or healing of a duodenal ulcer was also important. Using 113m In as a marker of the liquid, and 99m Tc as a marker of the solid phase, measurements of gastric emptying rates were undertaken in duodenal ulcer patients before, during and after therapy with cimetidine, as well as in control subjects. Before therapy there were no significant differences in the rate or pattern of gastric emptying in duodenal ulcer patients as compared with normal controls. This implied that gastric motor function in the two groups was similar, and the results did not agree with the findings of previous investigators who had found abnormally fast emptying in duodenal ulcer patients. During treatment, however, the emptying rate of particles became faster. The findings suggested that cimetidine had no marked effect on the emptying of the liquid component of a meal, but that there was a specific effect of the emptying of the solid phase. Gastric emptying patterns from control subjects and from healed duodenal ulcer patients were remarkably similar.

Williams et al. (l986) measured gastric emptying of citric acid, glucose and fat meals by means of a double-sampling, dye-dilution technique, while maintaining intragastric pH at a constant level. Acid, glucose and fat inhibited gastric emptying in a dose-dependent fashion in duodenal ulcer patients as well as in normal controls. Duodenal ulcer patients emptied all three types of meals faster than normals, but differences only occurred at the lower doses of glucose or with the less potent doses of acid and fat. It was concluded that differences in gastric emptying of liquid meals in duodenal ulcer patients, as compared with normals, were small; the variable responses obtained with different concentrations might explain some of the inconsistencies found by previous workers.

Hui et al. (l986) performed endoscopic biopsies in 213 patients with active duodenal ulceration and diagnosed active chronic antral gastritis in 99 percent. The degree of chronic inflammation was assessed histologically by the infiltration of polymorphs and chronic inflammatory cells and by the severity of mucosal degeneration. In the majority of patients antral gastritis was considered to be of a moderate degree. In non-ulcer controls active chronic antral gastritis occurred in 50 percent and in a milder form. It was concluded that the exact relationship of chronic antral gastritis to duodenal ulceration was uncertain. Healing of the duodenal ulcer was accompanied by histological improvement of the antral gastritis.

Present Investigations #

Patients and Methods #

We examined the contractile behaviour of the pyloric sphincteric cylinder in duodenal ulceration by means of upper gastrointestinal radiography in the following groups of patients:

Group 1. Sixty consecutive patients with active duodenal ulceration receiving and responding to medical treatment. All had been referred from the outpatient department with the clinical diagnosis of duodenal ulcer. In most cases the symptoms had been present for several months to a year; some had had symptoms and signs of chronic, recurrent duodenal ulceration and had received anti-ulcer therapy intermittently for the previous one to four years. Many had previous radiographic and/or endoscopic examinations, in which the diagnosis had been confirmed. Only patients in whom a definite ulcer niche could be seen radiologically or endoscopically in the duodenal bulb, were admitted to the study; patients with additional upper gastrointestinal pathology, e.g. gastric ulceration or hiatus hernia, were excluded.

Group 2. Seventeen cases of chronic recurring duodenal ulceration not responding satisfactorily to medical therapy. All had endoscopically proven active duodenal ulceration and all were candidates for the operation of sero-myotomy and parietal cell vagotomy.

In 58 of 60 cases of the first group, and in 15 of l7 cases of the second group, contractions of the pyloric sphincteric cylinder were normal. The following are examples from the 58 cases of the first group:

Case Reports #

Case 30.1. P.K., 44 year old male, a known case of duodenal ulceration, had received anti-ulcer therapy for some months; at the time of examination he was still symptomatic. Radiographic examination revealed no lesion in the oesophagus and stomach; the duodenal bulb was deformed and showed a niche on its lesser curvature side, indicating an active duodenal ulcer. Contractions of the pyloric sphincteric cylinder were normal. The distended cylinder contained several transverse (i.e. circular) mucosal folds (Fig. 30.1A). During contraction of the cylinder the folds changed in direction to longitudinal, only longitudinal folds being evident in the maximally contracted cylinder, with formation of the pyloric canal (Fig. 30.1B). The rate of cyclical contractions of the cylinder was normal at about 3 or 4 per minute. It is not possible to determine the amplitude of individual contractions radiographically; descriptions such as "maximal" or "near maximal" may give some indication of the degree of contraction. Radiographically the range and degree of contraction appeared to be normal.

AB
Fig. 30.1 A,B. Case P.K. A Transverse (i.e. circular) mucosal folds in distended pyloric sphincteric cylinder. Ulcer niche in duodenal bulb. B Normal contraction of sphincteric cylinder. Longitudinal mucosal folds in fully contracted pyloric canal. Ulcer niche in duodenal bulb

Case 30.2. W.C., 33 year old male, a known case of duodenal ulceration, presented with epigastric pain and malaena. Radiographic examination showed no abnormality in the oesophagus and stomach. The duodenal bulb was deformed and contained an ulcer niche (not clearly visible in illustration) (Fig.30.2A). Cyclical contractions of the pyloric sphincteric cylinder occurred at a rate of 3 to 4 per minute; the range of individual contractions appeared to be normal, varying from full expansion (Fig. 30.2A) to maximal or near maximal contraction (Fig. 30.2B). A month after the examination the duodenal ulcer perforated, necessitating laparotomy and omental plugging of the perforation; the stomach was normal at operation.

AB
Fig. 30.2 A,B. Case W.C. A Pyloric sphincteric cylinder distended. Deformed duodenal bulb due to active ulceration. B Normal contraction of sphincteric cylinder. Duodenal bulb deformed

Discussion #

In 73 of 77 cases of duodenal ulceration, cyclical contractions of the pyloric sphincteric cylinder were found to be normal in character, range and frequency. (It has to be reiterated that these features were determined while using a fluid barium suspension). Normal contractions were seen irrespective of the size of the ulcer, its exact position (whether located in the apex, centre of base of the duodenal bulb) and irrespective of the degree of deformity and/or narrowing of the bulb (in 9 of the cases there was appreciable narrowing).

In 2 of 60 cases in the first group in whom normal contractions of the cylinder were absent, the stomach was aperistaltic, hypotonic and moderately dilated, with delayed emptying in the erect position; this was not due to duodenal narrowing or obstruction, the cause of the aperistalsis being undetermined. In 2 of 17 cases in the second group with absent cyclical activity, atypical contraction of the cylinder was noted.

It has been stated that the acid-secretory characteristics of duodenal and pyloric ulcers are similar (Chap. 29). The present findings show that there are important differences in the motility patterns of the pyloric sphincteric cylinder in the two conditions. Normal contractions usually occur in duodenal ulceration while severe motility disturbances are present in pyloric ulceration (Chap. 29). The findings confirm those of Liebermann- Meffert and Allgöwer (l98l), who stated that motor disorders of the gastric musculature were less evident in duodenal than gastric ulceration and were, in fact, of minor importance in duodenal ulceration.

"Antral" gastritis may occur in cases of duodenal ulcer, but is usually of a mild, diffuse type; gastric ulceration is associated with much more severe inflammatory alterations, according to Schrager et al. (l967). Liebermann-Meffert and Allgöwer (l98l) found that abnormal features of the muscular layers and ganglion cells were less severe in duodenal than in gastric ulcer. Earlam et al. (l985) described a high incidence of chronic superficial and chronic atrophic antral gastritis in a selected group of duodenal ulcer patients, all requiring operation after prolonged but unsuccessful medical therapy. Brooks (l985) looked upon gastritis of the antral mucosa as a common finding in duodenal ulceration. Hui et al. (l986) found active, chronic gastritis in almost all patients with duodenal ulcer; in the majority it was of moderate severity.

The less severe grades of pyloric gastritis occurring in association with duodenal ulcer (as opposed to the more severe gastritis in pyloric and other gastric ulcers) probably accounts for the normal motility of the pyloric sphincteric cylinder in the former.

References #

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