38 - Prolapse of Gastric Mucosa into the Duodenum

Prolapse of Gastric Mucosa into the Duodenum #

In 1911 Schmiedin described a case of gastric outlet obstruction in which, at operation, a fold of gastric mucous membrane was found to have acted like a ball-valve at the pylorus. The fold could be pushed into the pyloric aperture. While the pre-operative radiographs demonstrated the fold, they did not show definite evidence of prolapse into the duodenum. At operation the fold was excised, resulting in complete recovery of the patient. This appears to be the first description of a case in which redundant gastric mucosa caused significant symptoms.

Eliason and Wright (l925) described a case of a 56 year old male who was operated on for a suspected benign tumor of the stomach. Before opening the stomach a doughy mass was felt projecting through the dilated pylorus into the duodenum. During palpation the mass slipped into the stomach and could not be pushed back into the duodenum. Gastrostomy showed that the entire mucous membrane of the pyloric region was freely mobile on the underlying muscle coat and that it could be pushed through the pylorus, causing invagination of a complete mucous membrane cuff into the duodenum.

Eliason et al. (l926) described a case of a 61 year old male in which the pre-operative radiographs showed a defect extending through the pylorus into the base of the duodenal bulb. It was thought to be a pedunculated tumor of the stomach but operation revealed redundant gastric mucosal folds extending through the pylorus into the duodenum. In another case, that of a 29 year old male, radiographs showed a similar defect in the base of the duodenal bulb. At operation it was found that the pyloric mucous membrane was freely mobile upon the muscle coat and that it had prolapsed through the pylorus into the duodenum. A healed duodenal ulcer was also present.

These appear to be the first recorded cases of prolapse of gastric mucosa into the duodenum. Since that time additional cases have been reported, and by l952 at least 80 verified and 177 unverified cases had been described in the literature. (Comment: "Unverified" indicates cases diagnosed radiologically but not verified by other means. It is possible that the radiological appearances in some of these cases might have been due to normal anatomical variations). These case reports were collected and analyzed in a thesis in which various aspects of the condition were considered (Keet 1952). Subsequently more cases have been reported (vide infra).

At present there appears to be uncertainty, if not scepticism, about the diagnosis, and a need exists for continued investigation of different aspects of the condition. In particular, it seems necessary to determine to what extent the pyloric mucosa is normally mobile in relation to the underlying layers of the wall, and if it is capable of prolapsing into the duodenum.

Normal Mobility of the Mucosa #

Cunningham (1906) pointed out that the mucosa of the stomach is closely bound to the submucosa which, in turn, is loosely attached to the muscularis externa. Forssell (l923, l939) showed that two types of mucosal movements exist: (1) co-ordinated movements of the muscularis externa and the muscularis mucosae, which determine to a large extent the size, shape and position of the macroscopic folds; (2) "mucosal autoplastik", i.e. the inherent ability of the mucosa to move, which accounts for the fine, surface mucosal patterns (Chaps. 2, 13).

Cole (l928) showed that the pyloric valve is normally displaced into the duodenum after death. This normal appearance may be mistaken for prolapse of gastric mucosa, and has to be kept in mind whenever the diagnosis of prolapse has to be considered at autopsy.

Golden (l937) stated that the gastric mucosa was normally freely mobile on the muscular layers. This could readily be demonstrated by the separation of mucosa from muscle wall in the fresh specimen at autopsy, as well as by the projection of the mucous membrane over the edge of the muscle when the living stomach was cut at operation. Scott (l946) confirmed this view, but stated that normally the extent of movement was not sufficient to allow prolapse of gastric mucosa into the duodenum. he found it impossible to pull the gastric mucosa through the pylorus into the duodenum by means of surgical forceps in a series of 126 autopsies in which the stomach was normal. There was one exception, a case of severe cardiovascular disease and myocardial infarction. In this case the gastric mucosal folds could be manipulated into the duodenum comparable to the appearance seen in prolapse of the mucosa at operation.

Bralow and Melamed (l947) examined a number of normal stomachs within three hours post mortem and found that a small amount of gastric mucosa could be pulled through the pylorus, simulating a minor degree of prolapse. Ferguson (l948) concluded from observations at autopsy that the mucosa of the normal stomach was movable relative to the muscularis externa, but in no case sufficiently mobile to allow it to be drawn into the duodenum. Manning and Highsmith (l948) confirmed Golden's observation that the gastric mucosa was freely movable over the muscular coat. Manning and Gunter (l950) concluded that there was a certain looseness of the antral mucosa in the normal. In prolapse it was exaggerated and redundant folds could lie in the pyloric aperture or could easily be drawn through the aperture into the duodenum for variable distances. Keet l952 examined 10 normal stomachs approximately 24 hours post-mortem and found that a fold of pyloric mucous membrane (the mucosal/submucosal component of the pyloric ring) projected into the lumen of the duodenum in every case, confirming the observation of Cole (l928). Surgical forceps were used to determine to what extent the mucosa could be elevated from, or shifted on, the underlying layers in a 2.0 cm wide band on the oral side of the pyloric aperture, i.e. in the pyloric sphincteric cylinder. In a child 8 years of age it was not possible to elevate or shift the mucosa. In all adults the mucous membrane could be lifted from 5.0 mm to 1.0 cm from the muscular coat. Such a fold could be pulled beyond the pyloric ring (right pyloric loop) for a distance of 5.0 to 10.0 mm into the duodenum. At distances greater than 2.0 cm from the aperture it was still possible to elevate the mucosa into folds, which could be moved in all directions but could not be drawn into the duodenum. It was concluded that a certain degree of prolapse of the gastric mucosa could be produced artificially in adults at autopsy by traction on the mucosa close to the pyloric aperture. The greatest extent to which the mucosa could be drawn into the duodenum was one centimeter. Anything greater than this should probably be regarded as abnormal, and in young persons the distance was probably much less.

Williams (l962) examined aspects of the mucosa in 48 fresh post-operative partial gastrectomy specimens, removed because of gastric or duodenal ulceration. The gastric mucosa was found to be soft and pliable and to move easily over the muscularis externa. This was due to the fact that the gastric submucosal coat is normally much wider than that of the duodenum (Chapter 4). Finger pressure could push the mucosa into the pyloric ring, but owing to its attachment at the ring it rose in thebase of the duodenal bulb in a circumferential, two-layered fashion, like a clerical collar. In all cases a mucosal protrusion of 1.0 to 3.0 cm into the duodenum could be produced in this way. According to Williams (l962) a similar minor degree of physiological herniation of gastric mucosa into the base of the duodenal bulb frequently occurs during forceful contraction of the "pyloric press".

Pathoanatomical Diagnosis #

In the 2 cases of Hawley et al. (l949) which came to autopsy it was found that the gastric mucosa slid easily over the muscularis and could be lifted through the pylorus for distances of as much as 2.5 cm. This was considered to be definitely abnormal. In 2 of the 6 cases studied by Manning and Gunter (l950) the submucosa was very loose, slipping freely over the muscularis, and the redundant antral folds could be drawn into the duodenum for a distance of 2.0 cm. In both cases the entire circumference of the mucosa was involved. Histological examination showed chronic inflammatory change in the prolapsed mucosa, submucosa and muscularis mucosae. There appeared to be some hypertrophy of the musculature of the pyloric "sphincter". In 2 of the cases the prolapse consisted of tongue-like projections of gastric mucosa extending into the duodenum. In the 2 other cases in whom a radiological diagnosis of prolapsed gastric mucosa had been made, the patho-anatomical findings were not quite convincing and in our opinion could have been due to post mortem projection of the mucosal part of the pyloric ring into the duodenum.

Zimmer (l950) as well as Manning and Gunter (l950) stated that many pathologists failed to search for the condition at autopsy. The following features were considered to be typical of gastric mucosal prolapse: (1) gross protrusion of gastric mucosa into the duodenal bulb which is quite evident as soon as the stomach and duodenum are opened; (2) the mucosa may not protrude through the aperture but can easily or readily be drawn through it. The latter statement should probably be qualified by the provision that normally the gastric mucosa can be drawn into the bulb for a distance of one centimeter.

Surgical Diagnosis #

If the stomach and duodenum are exposed and inspected at operation, no abnormality will be seen in uncomplicated cases. At palpation no abnormality may be felt in either the stomach or duodenum, as the prolapsing mucosa is so soft that it cannot be felt through the walls (Rendich l923; Eliason et al. l926). A softish mass may be felt in the duodenum (Ferguson l948) or in the pyloric region while the duodenum feels normal (Schmiedin 1911; Norgore and Shuler 1945; MacKenzie et al. 1946; Zacho 1948; Nygaard and Lewitan 1948; Teng 1962). In some cases a doughy, tumor-like mass could be felt in the duodenum, which disappeared under palpation (Eliason et al. 1926; Bohrer and Copleman 1938). In others it could be slipped back and forth between the stomach and duodenum (MacKenzie et al. 1946; Nygaard and Lewitan 1948).

Because of these features all stomachs should be opened at operation whenever the condition is suspected (Scott 1946). In the cases quoted above, folds of redundant gastric mucosa were seen after the stomach had been opened. In several cases big prepyloric folds occluded the aperture, acting like a valve (Schmieden 1911; Eliason et al. 1926; Zacho 1948; Keet 1952, 1953). In other ocases the incision was carried through into the duodenum. When both the stomach and duodenum were opened, redundant folds of gastric mucosa protruding into the duodenum were usually quite evident (Meyer and Singer 1931; Bohrer and Copleman 1938; MacKenzie et al. 1946). In most cases the prepyloric folds were movable on the muscular coat and could easily be pulled into the duodenum for variable distances (Rees 1937; Ferguson 1948; Hawley et al. 1949). In the case of Hawley et al. (1949) for instance, the pyloric mucosa could be drawn through the aperture for a distance of 2.0 cm. In one of the cases described by Rees (1937) the largest gastric mucosal fold was 3.0 cm in height and 4.0 cm in length. It could be pushed through the pylorus into the duodenum with ease. 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. In three of our verified cases the size of the defect in the duodenal bulb was seen to be related to the degree of contraction of the pyloric sphincteric cylinder (Keet 1952). In these cases a shallow defect might be visible during relaxation or inactivity of the cylinder. During contraction the duodenal defect became more extensive, reaching its greatest volume with maximal contraction of the cylinder. The same feature was seen in most of our unverified cases as well. It was not unusual for the duodenal bulb to appear normal prior to contraction of the cylinder, with the defect only appearing during contraction.

In contrast, Stiennon (1960) noted that tortuous prepyloric rugae sometimes "prolapsed backward", i.e. in an orad direction, through an advancing peristaltic wave. In most cases a somewhat stronger or tighter wave finally forced the mucosa through the pylorus. A similar phenomenon was described by White et al. (1966), who reported that the hyperaemic and oedematous prepyloric folds pushed back into the stomach as the "sphincter" closed. It was shown in Chapter 13 that orad movement of the mucosa in the pyloric sphincteric cylinder may occur normally during contraction of the cylinder. Furthermore sessile mucosal polyps in the cylinder may move in an orad direction during contraction of the cylinder (Chap. 36).

Levin (l97l) again stated that the duodenal defect of prolapsed gastric mucosa became more prominent during "gastric systole", and that the shape of the bulb reverted to normal during "gastric diastole".

The following are examples of further cases encountered by us:

Case Reports

Case 38.1 J.S., 35 year old male had intermittent, burning epigastric pain apparently related to meals, for the previous 5 years. Large meals occasionally caused vomiting. Clinical examination was negative. Radiology revealed no abnormality in the oesophagus and stomach. During phases of distension or partial contraction of the pyloric sphincteric cylinder, the duodenal bulb appeared normal (Fig. 38.1A). With maximal contraction of the sphincteric cylinder an umbrella- like or mushroom-like defect appeared in the base of the duodenal bulb; it was continuous with longitudinal mucosal folds extending through the fully formed pyloric canal (Fig. 38.1B), and the diagnosis of prolapse of gastric mucosa into the duodenum was made. Gastroscopy showed a few prominent mucosal folds which appeared to be redundant and capable of prolapsing into the duodenum. No evidence of ulceration or other pathology was seen.

Fig. 38.1 A. Case J.S. Partial contraction of pyloric sphincteric cylinder. Base of duodenal bulb normal

Fig. 38.1 B. Case J.S. Maximal contraction of sphincteric cylinder. Umbrella-like defect base of bulb, continuous with longitudinal mucosal folds in pyloric canal

Case 38.2 A.A., 20 year old male, a known case of duodenal ulceration, had received anti-ulcer therapy for the preceding year. Because of a recurrence of symptoms radiographic examination was requested.

Several prominent, tortuous mucosal folds were seen in the pyloric sphincteric cylinder while it was relaxed; the base of the duodenal bulb appeared normal, but there was a possible ulcer near its apex (Fig. 38.2A). During maximal contraction of the pyloric sphincteric cylinder an umbrella-like defect appeared in the base of the duodenal bulb, continuous with longitudinal gastric mucosal folds stretching through the fully formed pyloric canal (Fig. 38.2B). The case was diagnosed as prolapse of gastric mucosa and probable active duodenal ulceration. Control double contrast radiographic examination a month later failed to show the prolapse. At this examination administration of an anticholinergic substance relaxed the gastric walls and insufflation of air caused luminal distension, factors which prevented the sphincteric cylinder from contracting.

Fig. 38.2 A. Case A.A. Prominent, tortuous mucosal folds in relaxed pyloric sphincteric cylinder. Base of duodenal bulb normal. Possible duodenal ulcer

Fig. 38.2 B. Case A.A. Maximal contraction of sphincteric cylinder. Umbrella-like defect base of bulb, continuous with longitudinal mucosal folds in pyloric canal

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.

Relationship to Cyclical Activity of Sphincteric Cylinder #

In the present cases as well as in some of those described previously (Keet l952) it is clear that prolapse of gastric mucosa may only occur during maximal contraction of the pyloric sphincteric cylinder. A number of other authors came to essentially similar conclusions, although they used terms such as "antral systole", "gastric systole" and "peristaltic activity" to indicate the concept of contraction of the sphincteric cylinder (Nygaard and Lewitan l948; Fermin l950; Zimmer l950; Levin l97l). According to Bralow and Melamed (l947) prolapse ensued when there was failure of the normal orad movement of the mucosa during "antral systole" as originally described by Golden (l937) (Chap. 13). In our view prolapse almost amounts to expulsion of gastric mucosal folds into the duodenum, together with luminal contents. It is surmized that it may indicate failure of the normal mechanism of "independent but co-ordinated" contractions involving the muscularis externa and mucosa, as described by Forssell (l923, l939) (Chap. 2, 13). It seems as if the occurrence of prolapse depends on the degree of contraction of the pyloric sphincteric cylinder, rather than the position of the patient, in many cases.

On the other hand prolapse of gastric mucosa into the duodenum may also be fickle and unpredictable; its occurrence and extent may vary between examinations and even during a single examination.

The Radiological Differential Diagnosis #

Normal. A number of authors have commented on the fact that the base of the duodenal bulb may normally have a semicircular or concave outline, which may easily be mistaken for a semicircular or mushroom-shaped defect due to prolapsed mucosa (Scott 1946; Bralow and Melamed 1947; Manning and Highsmith 1948; Hawley et al. 1949; Keet 1952; Todd and Brennan 1957). The concave defect often becomes more prominent during maximal contraction of the pyloric sphincteric cylinder (Chap. 13).

Depending on the direction of the pyloro-duodenal axis, the circular indentation of the base of the bulb caused by the normal pyloric ring, may sometimes appear to be exaggerated. This is especially evident when the bulb is seen obliquely from the base. If, in addition the sphincteric cylinder is contracted, producing longitudinal mucosal folds running toward the aperture, the appearance may mimic prolapse closely. In one of the illustrations of Rappaport et al. (1952), a round defect of the base of the bulb with radial striae of barium was said to indicate prolapse of gastric mucosa; however, this could just as well have been a normal stage of contraction of the cylinder. There seems to be little doubt that in many instances, and perhaps even in the majority of non-verified cases, the radiological diagnosis rested upon faulty interpretation of these normal appearances, leading to false positive diagnoses.

Adult Hypertrophic Pylorid Stenosis. A number of authors mentioned adult hypertrophic pyloric stenosis in the differential diagnosis (Pendergrass and Andrews 1935; Scott 1946; Hawley et al. 1949; Keet 1952). In this condition the hypertrophied musculature of the pyloric sphincteric cylinder indents the base of the duodenal bulb, producing a concave defect which may be mistaken for prolapse. The narrowed pyloric canal contains longitudinal mucosal folds converging on the aperture, again mimicking prolapse (Chap. 24). In adult hypertrophic pyloric stenosis the bulbar defect is due to pressure from without, and tends to be constant. In prolapse there is an intraluminal bulbar defect which tends to change in size and shape. Differences are also seen in the motility of the cylinder in the two conditions. Whereas the cylinder may contract and expand normally in prolapse, it remains more or less permanently contracted in hypertrophic stenosis. A complicating factor is that prolapse of gastric mucosa may co-exist with adult hypertrophic pyloric stenosis or narrowing and constriction of the cylinder (Pendergrass and Andrews 1935; Archer and Cooper 1939; MacKenzie et al. 1946; Zacho 1948; Manning and Gunter 1950; Keet 1952).

Prolapsed Benign Pedunculated Gastric Polyps. Prolapsed polyps have long been known to produce rounded defects in the duodenal bulb (Eliason et al 1926; Pendergrass and Andrews 1935). Short and Young (1968) collected 30 cases from the literature and found the majority to be benign adenomas. However, prolapsing lipomas, myomas, fibromyomas and other types of benign gastric polyps may occur. A feature of these defects is that they may vary in position, at times being seen in the confines of the sphincteric cylinder and at other times in the duodenal bulb.

Prolapsed Primary Gastric Carcinoma. Occasionally a prolapsed primary gastric carcinoma may produce a rounded intraluminal filling defect in the first part of the duodenum. Joffe et al. (1977) described 4 cases of this nature, all gastric adenocarcinomas, 2 being pedunculated and 2 sessile (Chap. 33).

Associated Gastroduodenal Lesions #

Most cases of prolapse of gastric mucosa into the duodenum occurred de novo, in the absence of other lesions of the upper gastrointestinal tract. However, in a considerable number of cases other lesions were also encountered during the radiological, surgical or post mortem examinations. The most frequent associated conditions were the following:

Duodenal Ulceration. Not infrequently active duodenal ulceration was encountered (Pendergrass 1930; Scott 1946; Manning and Gunter 1950; Zimmer 1950; Keet 1952). Cases associated with healed duodenal ulceration were also described (Eliason et al. 1926; Archer and Cooper 1939; Fermin 1950).

Gastric Ulceration. Melamed and Hiller (1943) described a case in which a large gastric ulcer was situated on the prolapsed mucosa. In other cases active gastric ulceration was located elsewhere in the stomach, i.e. away from the prolapsing mucosa (Hawley et al. 1949; Keet 1952).

Changes in the Pyloric Musculature. Changes of a hypertrophic or fibrotic nature in the pyloric musculature with consequent narrowing of the pyloric aperture were reported by various authors. Meyer and Singer (1931), Archer and Cooper (1939) and Zacho (1948) noted a perceptible thickening in the pyloric musculature in some of their cases. In a verified case of Ferguson (1948) the pyloric muscle was greatly hypertrophied. In his 3 cases Rees (1937) found the pyloric muscle to be constricted, having the appearance of a white fibrous ring in one case. Manning and Gunter (1950) noted thickening of the pyloric muscular ring in 4 of their 6 cases. Zimmer (1950) described a case with a duodenal ulcer and acute inflammatory changes in the pyloric mucosa and musculature. From these descriptions no clear picture emerged as to the nature and extent of the pyloric hypertrophy.

Cases with an abnormally wide pyloric aperture have also been described. Eliason et al. (1926) noted this feature in one case which came to operation. In the cases described by Nygaard and Lewitan (1968) and by Köhler (1950), the radiographs showed the pyloric aperture to be widely dilated.

Gastritis. Differences of opinion regarding the histology, pathogenesis and classification of gastritis have been referred to previously (Chap. 28). In the present context it is to be expected that different authors may have used different criteria in diagnosing gastritis. A number of cases of transpyloric prolapse of gastric mucosa have been described in which "gastritis" was mentioned as an associated lesion.

Bohrer and Copleman (1938) described one case in which there was associated acute and subacute gastritis. In two verified cases of Norgore and Shuler (1945) the pyloric region showed evidence of chronic gastritis. Histological examination of the resected mucosa in 5 operated patients described by Scott (1946), showed a slight increase in lymphocytes, plasma cells and eosinophils throughout the mucosa and submucosa; however, this was not considered sufficient to warrant a diagnosis of gastritis. Judd and Moe (1947) described a case in which erosive gastritis and infiltration by plasma cells were present. A verified case described by Nygaard and Lewitan (1948) had chronic gastritis and healed erosions. One of the 3 verified cases of Hawley et al (1949) showed a moderate infiltration of the gastric mucosa with plasma cells and lymphocytes. The second case showed no gross evidence of gastritis, and the third, in which 2 gastric ulcers were also present, had acute on chronic inflammatory reaction in the pyloric area. Two cases of verified circular prolapse studied by Manning and Gunter (1950) both showed chronic gastritis with heavy infiltration of lymphocytes and plasma cells in the prolapsed mucosa, submucosa and muscularis mucosae. In his verified case Teng (1962) found the submucosa to be thickened and oedematous; there was mild inflammatory reaction without ulceration. White et al. (1966) found the prepyloric mucosal folds to be hyperaemic and oedematous with a granular, inflammatory appearance.

Possible True Complications #

Ulceration and Haemorrhage. Cases with superficial ulceration of the prolapsed mucosa and consequent slow oozing of blood from the ulcerated surfaces were described by a number of authors (Pendergrass and Andrews 1935; Bohrer and Copleman 1938; Archer and Cooper 1939; MacKenzie et al 1946; Scott 1946; White et al. 1966). In some cases massive gastro-intestinal haemorrhage occurred (Ferguson 1948; Moon and Speed 1949; Fredel 1960). The above authors usually regarded ulceration and haemorrhage as a true complication of the condition.

Obstruction of the Pyloric Aperture by Redundant Gastric Mucosal Folds. Gastric mucosa prolapsing into the duodenum may, at times, pile up in the form of large, redundant prepyloric folds causing obstruction at the gastric outlet (Schmiedin 1911; Eliason et al 1926; Scott 1946; Judd and Moe 1947; Zacho 1948; Fredell 1960). (In the 2 cases of Zacho there was associated pyloric muscular hypertrophy). It seems that redundant prepyloric mucosal folds, causing obstruction, may also be regarded as a true complication.

Malignancy and Prolapse of Gastric Mucosa #

Malignancy does not appear to be a complication of gastric mucosal prolapse. The presence of benign papillomata on prolapsed mucosa was reported by Pendergrass and Andrews (1935). In one of the polyps a small plaque of malignant tissue was encountered; it was considered to be an incidental finding not directly related to the prolapse. One other case associated with malignancy was described, namely that of Rubin (1942), in which the malignant polypoid process involved the entire gastric mucosa. This appeared to be a case of general gastric polyposis with malignant degeneration, not confined to the prolapsed mucosa. According to Nygaard and Lewitan (1948) no instance of malignant change in a true case of transpyloric mucosal prolapse had been reported up to that time. This statement still appears to be valid at the present time. However, a primary gastric carcinoma may prolapse into the duodenum, causing a rounded, intraluminal filling defect in the bulb, as described by Joffe et al. (1977).

References #

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