stand by Sir.
The following is a medical media production from
W.R.A.M.C.T.V.
The gastro Kantra um is
a portion of the stomach which both structurally and
functionally is considerably different from the more
proximal aspects.
It may seem to be gilding the lily a little bit
to subdivide
a relatively simple muscular sac
into different portions.
But so many things can affect the distal
Antrim,
which are not necessarily seen in either the
same fashion or to the same extent in the more proximal
stomach,
that it is advisable to consider
its components separately.
In the past,
the Antrim has been described as that
portion of the stomach between the inside,
sure,
angular iris and the pile oric valve.
And indeed that would seem to be a logical
uh separation of the two
portions of the stomach.
However,
uh if you watch
the paris Tallec cycle,
you find that what represents the paris
Tallec valve in one portion does not
necessarily have the same appearance in another
ensured a structure that normally is about a half a
centimeter in length,
suddenly becomes about 2.5 centimeters in
length and it's really rather difficult to say where
the pile oric valve exactly actually
begins and stops.
Uh the reasons for this lie within
the structure of the Antrim,
the muscular structure and it were
recognized many years ago,
both by four shell.
Alvarez and others and various
terminologies have been suggested.
Uh this by
uh Alvarez,
this by four shell.
I find this one personally a little easier to remember
and have more or less adopted it from my personal
use,
but the connotation of the names in either area is
exactly the same.
Four shell still describes the Antrim as that portion
between the inside,
sure angularity and the pile oric valve,
but describes this segment which can change in
length from approximately a half to 2.5
centimeters as the Canalis
Pastorius,
rather than referring to it as simply as
the pre pile oric segment,
the more proximal portion of the Antrim between the
canal.
Asi gassed aureus and the
inside sure angularity is referred
to as the sinus.
Now for practical purposes,
the so called pars pile Orica of
Alvarez and the pile orrick,
Antrim of alvarez are
identical respectively with the sinus and
the canal asi gassed aureus.
I think you can see why this might be confusing to
try and remember the difference between the two.
The term or a variation of the term pie loris is used
three times over a short segment and this seems to
be a little more readily
remembered now,
even though this portion of the stomach differs
both functionally and
structurally from the more proximal portions,
they're an integrated whole.
And you can't really understand the functions of one
unless you understand the functions and structure of the other
and for that reason go back for a moment and
review the gross anatomy of the
muscular layers of the stomach.
Now the outer layer is a longitudinal
one which is continuous with the
longitudinal muscle of the esophagus.
It's actually in two fairly well
defined coats over the greater
and lesser curvature of the stomach.
But it is really a continuous code,
it's just a little thinner on the anterior and posterior
walls.
And as you approach the more distal portions of the stomach,
it becomes a little more compact
actually for performing uh
excuse me forming a
structure uh in
the distal stomach,
the functions of which are not exactly known but which
are uh separable from the main
bulk of the muscle.
Now,
the circular muscle also is
continuous with that of the esophagus,
sweeps down throughout the entire
stomach to the pile orrick area where
it also compacts.
And it is from this compaction of the circular muscle
that the highly specialized fibers of the pile oric
complex,
or the Canalis,
egoist aureus are formed
in general.
The circular muscle of the stomach is heavier
than the longitudinal muscle,
and it also differs in the fact that it
stops abruptly at the pile
oryx sphincter at this point where a
muscular of member his diaphragm rather
separates it from the duodenum lumen
In contradistinction are the longitudinal fibers
which do pass over about 50% of them
to join with the longitudinal fibers of the Duodenum.
Now we'll come back to the structure of the pile orrick muscle in a
moment.
But it's important that we recognize that
they are in essence specialized portions of
the circular fibers of the stomach,
to which the longitudinal fibers
do contribute a portion of the
structure,
and we'll show you that also a little later.
Now there's a third muscle there,
the so called oblique fibers,
and there's considerable dispute as
to what precisely these represent.
Initially they were regarded as a specialized group of
muscle fibers that developed in
the human being to serve a supportive function
as we walk on two legs as opposed to four
uh In some of the other mammals,
this probably is an oversimplified
explanation of the function of
the,
of the oblique fibers.
It has been postulated but not
proven that they are a conductive
system,
that they are analogous to the bundles of hits of the
heart,
and that they distribute certain
impulses to the remainder of the muscle
fibers of the stomach.
Be that as it may,
their structure is rather unique.
There's a relatively heavy collar that
surrounds the juncture point of
juncture of the esophagus and stomach,
and from this collar
the fibers descend on either side of the lesser
curvature and sweep out toward the greater
curvature aspect,
intermingling with the circular fibers fibers
about halfway around the curvature.
For practical purposes,
there is no oblique structure
along the lesser curvature proper,
except for a few tiny crossover
connecting fibers.
For practical purposes,
this part of the stomach contains no
oblique fibers.
In addition,
the oblique fibers stop abruptly at the inside.
Sure,
angular,
and the muscle distal to the inside,
sure,
angular,
Is consists of the circular and longitudinal bands.
Only not the
oblique fibers.
Now whether or not this is actually a
conductive bundle is open to question.
It's very difficult to prove because these fibers are so
intermeshed.
They're hard to dissect out,
let alone to ascribe a particular function to
each given set.
But there is a difference when you
stimulate certain areas of the stomach.
For example,
if you put a
galvanic current at this point
you will get a foreshortening of the stomach
but no insight.
Sure.
A formation.
Whereas if you stimulate anywhere along the
distribution of the uh
the uh oblique fibers you will get a
characteristic insight.
And as I mentioned to you the other day
it is thought that the
formation of an insight sure in the presence of benign
disease represents stimulation of these fibers
by the benign process.
Usually in a peptic ulcer or some form of
inflammatory disease.
This being the case one would expect to see inside.
Sure is in this area with peptic ulceration
but none in this area since these fibers do not
exist distal to the inside.
Sure,
angularity and in fact that is what you do see
you may see partial spastic contraction of the
circular muscle fibers,
but these are so specialized in terms of the
final structural appearance of these fibers that
they're recognizable as such and separate and
distinct from the inside that
develops in the more proximal portions of the stomach.
One last
observation about these oblique fibers.
Before we go on to the other
aspects of the Antrim,
you notice that this rather heavy
collar here embraces the entire esophageal
gastric junction.
Actually,
if you look at this uh in the
specimen,
the collar interior really is not quite as well
developed as it is laterally and posterior early,
but by and large,
it's a very well defined segment
and it delineates a portion of the stomach that has been
referred to as the Antrim cardiac.
Um and having been given that name many,
many,
many years ago by the old anonymous.
It has by and large been forgotten by everybody,
but it's a funnel shaped portion of the stomach that
lies between the distal esophagus and what we
commonly refer to as the fund us
and it changed positions.
It's a very evanescent structure.
You see it and suddenly you go to take a film of it and
it's gone.
Its configuration.
Its ability to be identified varies
greatly in the individual,
not only from examination to examination,
but actually from moment to moment.
The thing that I find so fascinating about it is
that if you watch a patient have a
gaseous irritation or vomit for
example,
you will see a
relaxation of this area
with expression of the gastric
contents into the esophagus.
When that expression stops this will contract
and the configuration of the Antrim cardiac
changes.
If you take sini films of this area,
you can identify the various phases of the
configuration sometimes and
it's interesting that although everyone talks
about a sphincter in the distal
esophagus,
as you all know,
it has never really been identifying anatomically.
It's a structure or a function that has been
identified on the basis of pressure readings
rather than an actual an atomic
uh structure.
And I have a strong suspicion
and I'm sure many will not agree with me that the
inferior esophageal sphincter actually
represents the circular fibers of the oblique
muscle and that this is the true sphincter mechanism
between the esophagus and the stomach.
If you ask me if I can prove that the answer is no.
And I've spent a good deal of time trying to think of a method by
which we might prove it and I haven't been very
successful.
One or two others have tried it with an equal act of success.
So it's just an observation for your interest.
It doesn't necessarily hold true.
Now again,
the distribution of these oblique fibers has seen
along in this schematic with the greater curvature
aspect of the stomach open is around the esophageal
gastric junction,
down along either side of the lesser curvature and
then fanning out toward the greater curvature
aspect with cessation at the inside shore
angularity distal to this point,
the highly specialized structure of the
circular fibers begins and this
forms what we can best describe as
the pile orrick complex,
a group of highly specialized muscular
structures that go to make up a series of
sphincter eric mechanisms rather than the
usual diaphragm type of muscle
that we consider to exist between
the duodenum and the distal stomach.
These fibers have a roughly fan shaped
appearance as you see here and there are two of
them,
a proximal and distal sling.
So called.
We're looking at this from the greater curvature aspect and
you note that in the fan shaped,
the widest aspect is on the greater curvature
side and that the fibers have a tendency to
condense toward the lesser curvature side
and form a relatively
thick bundle which is known as the
Taurus.
This is true of both the
uh proximal and distal
slings.
Between them is a gap of
relatively thin muscle.
Again,
one which is
identifiable in the pile orrick sequence,
as you will see in a moment.
Now looking at these in another way and
also comparing for example,
uh the rabbit dog and man,
we see that there is a roughly
comparable structure in the pile orrick area.
Once again a proximal
thickened spanked eric bundle
excuse me,
a distal thickens fink terek bundle,
a proximal spanked eric bundle which gather
together on the lesser curvature aspect to form a
knot and then the relatively thin
fibers in between the two sphinx,
eric bands,
which are nonetheless considerably thicker than the
circular muscular muscle and the more proximal portions of
the stomach.
These have the fan shaped appearance that I described
or may also be roughly
uh compared to a
cross,
the point at which the to join has
been described as the muscle Taurus or muscle
not,
and this may be respect these maybe respectively known
as the distal and proximal sphincters,
or the right and left sphincters,
as you will because of the
relatively underdeveloped muscle between
these two heavy bands.
When these contract,
there is a tendency for the greater curvature aspect
between the two to bulge,
and this has been termed the la Oculus of
the pylori complex.
Again,
this can be seen in the gross specimen
in this case from a dog.
This is the duodenum side,
the gastric side,
and you see this roughly fan shaped
appearance with a relatively heavy muscle in the
region of the Taurus and fanning out on either
side of the gastric Antrim
schematically
depicting what happens during the paris Tallec
cycle.
We can see why,
for shell use the terminology of
canalys egoist aureus rather than the simple term
pylori valve,
with the Antrim completely relaxed,
filled with barium.
We see only the distal sling
the right portion of the pie Lorik
sphincter,
and that is what we are accustomed to identify as the pile
oryx sphincter,
and that is the structure that usually measures 4 to
5 millimeters in width.
The remaining remainder of these structures are not
identified with the Antrim relaxed.
However,
as this sling like muscle begins to
contract.
We then have a thickening of
this sling which clearly delineates the base of the
duodenum ball begins to elongate the
distal portion of the Antrim.
The more proximal portion,
which is slightly less well developed
than the distal sling also produces a similar
deformity,
but a little less marked because of the
underdevelopment of the proximal sling and between the
two,
the Oculus.
There is no out patching on the lesser curvature aspect
because of the buttressing effect of the pile
orrick muscle.
Not this whole thing when it's contracted,
covers a distance of 2 to 2.5 centimeters
and forms the canal.
Asi gassed aureus as compared to the so
called pylori valve.
Now this can be seen in the normal sequential
contractions of the Antrim flores,
ka pik,
lee,
or in a sterile.
A graphic study.
Here we see peristaltic wave
begin in the proximal stomach and sweep
down to approximately this point.
It does not begin in the region of
the uh
Asafa,
go gastric junction and progress sequentially all
the way down to the duodenum.
It goes down to a point just distal to the inside.
Sure angular is where it stops.
It holds at this point,
and then the contraction of the pile or a complex
begins,
and here you see a slight flattening
representing a beginning contraction of the Taurus.
This would be the area representing
the uh distal sling
as the contraction proceeds,
the volume of the Antrim diminishes the
peristalsis holds at this point and we begin to
see a second contraction developing here,
this progresses and concomitantly there
is thickening of the distance between the Antrim
and the base of the duodenal bulb,
representing respectively contraction of
the distal sling,
contraction of the Taurus and
contraction of the proximal sling with beginning
formation of the la Oculus at the thinned area
between the two slings.
This progresses to this point where you have total
contraction and then we see the characteristic
parallel folds of the mucous membrane with
complete emptying.
Now that represents the
muscular structure function of the
pile.
Or let's go for a
moment to the mucous membrane
and the secret ori aspects of the pilot.
This is a photograph from a
specimen of the gastric mucosa.
You see the folds and here
the area gastric which are
defined peripherally by the salsify
gastric.
If we look at this with a scanning electron
microscope,
the details are quite clear.
Here are the salsa.
Here are the individual area and
these little punk Tate shadows in
the apex of the area represent the orifices of
the gastric glands.
If this is specimen is
painted with barium.
Once again,
we can see the individual area outlined by the
salsa gastric and
here in this in vivo specimen,
they're readily identified throughout the
entire Antrim.
Now,
as I mentioned to you yesterday,
we see them easily here because of the paucity of
mucosal folds as compared to the more proximal portions
of the stomach,
but they are present and approximately the same size and
numbers throughout the entire stomach.
The reason that I bother to show them to
you insofar as the Antrim is
concerned is because the
Antrim is both functionally in
terms of muscular
motility and uh in
terms also in terms of secretary function,
probably the most active portion of the stomach.
And when inflammatory processes involve the
stomach usually they tend to
involve the Antrim to a greater degree
than the more proximal portions.
Now this of course,
is a generalization.
It's not always true but by and large.
For example,
when gastritis is present,
it's more readily identified and is a little more severe in
the Antrim than it is in the more proximal portions of the stomach.
And one method by which gastritis may be
identified is when you can visualize the
area throughout the entire stomach rather readily.
Here we see them in the entire Antrim and
approximately into the body and so on.
When this is accompanied with an
increased mucus content of the
stomach,
you can make a diagnosis of acute
gastritis with considerable
confidence
this is the same individual that you just saw
and hear this intense edema of
the gastric wall,
uh injection of the gastric wall and
superficial erosions corresponding
to the diagnosis of gastritis.
Now to carry that a step
farther,
a case of acute so called flag menace
gastritis with multiple alterations along the lesser
curvature aspect,
but notice that the
Antrim is diminished in volume normally,
this should be at least of
greater volume than we see here approximate
the more proximal portions of the stomach.
Uh It's quite reduced as compared to the
remainder of the stomach,
and the canal.
Asi gassed aureus is partially contracted
and indeed when we watch this flores copy clean,
ever ballooned out to its usual caliber
insured,
it had a spastic appearance.
Now,
this merely buttresses what I had to say a moment
ago that there is a diffuse process
involving the whole stomach,
but it's more
accentuated in the Antrim than it is approximately.
And this is related to
the presumably to the
relatively active part that the Antrim plays
in the normal gastric cycle.
Now,
if this is the case then one would expect with any with
disease that's present for any period of time,
that permanent changes would develop in the Antrim
before they would begin to appear in the more proximal portions
of the stomach.
And indeed,
here you see a case in point.
This is a patient with
a an acute gastritis,
but one which is recurrent.
He's had repeated bouts before you
see that the entire Antrim is funneled,
the canal is elongated and we also see these
irregular ineffectual contractions along the greater curvature
aspect,
which are so common in people with an
acute gastritis to carry this to
even more logical extent.
Here is a patient in whom the the Antrim has
funneled,
the mucous membrane is prominent and gassed risk
optically he had a rather
acute gastritis,
but one which had been present intermittently for long
periods of time.
He was placed on treatment and we saw him again
a year later and this is what he looked like.
One year later,
the Antrim is virtually non existent.
It's contracted stenosis virtually
obliterated,
and this is due to fibrosis,
and this is a type of disease that has been
called uh fibrosis in Antrel
gastritis,
in other words,
a gastritis which is involving the entire
stomach but predominates in the Antrim.
And because of the factors that we have
discussed presumably winds
up producing more permanent
uh more destructive changes in the Antrim
as opposed to the remainder of the
stomach.
Now,
I think it's quite obvious that you have a real problem here in the
differential diagnosis between this and gastric cancer
and possibly pylori hypertrophy,
and this has to be born in mind
ulceration when it occurs in the Antrim,
as we've indicated,
does usually frequently doesn't
do the same thing as it does in the more proximal portions
of the stomach.
Here's an acute pile orrick ulcer.
And uh usually one thinks if you have a
pile oric ulcer,
you're going to have obstruction but that's not the case
with acute ulcers for some reason which I
don't profess to understand completely the pile
orrick muscle in the presence of
an acute ulceration very frequently is
flaccid rather than spastic.
And the end result is that you have a wide open
pile oris which readily empties the contents of the stomach.
Now,
if that also persist for a while and Cronus
city uh is present,
then we see a contraction of the Antrim.
Here's the crater which parallels to
all
purpose is the uh an
atomic structure of the pile orrick musculature
that I pointed out to you.
There's a contraction of the proximal and distal slings as well as
the Taurus and it produces this long defect.
And unless you recognize the structural
characteristics of the Antrim,
this could be misdiagnosed,
for example as a cancer.
Now the next most common thing that we
see of course is a pile orrick hypertrophy
and this is commonly recognized as a disease of
infants.
It may show up immediately in the post natal period
or may not appear for several weeks or months.
Uh Usually it's diagnosed rather
readily.
The child is vomiting.
Uh If the abdomen is pal pay,
did you very frequently can feel the hypertrophy uh
mass representing the thick and
pylori muscle?
Uh If you
take a plain film of the abdomen,
you can see evidence of outlet obstruction on some
occasions,
and this is frequently felt to be sufficient
to make the diagnosis.
You notice that it's in this drawing by frank
netter,
how massive the pile orrick muscle is.
This is not just a simple hypertrophy of that
iris like structure that is normally regarded as
a pile or is but obviously involves the entire
segment of the pile or is all of its components?
This being the case.
This is probably why these Children are symptomatic.
If just a portion of it were involved,
we probably would not have uh the
characteristic symptoms
radiologic lee.
This is seen as an elongation of the pile orrick
canal.
And I think it's probably worth pointing
out to you that although surgeons are apt to
get unhappy with putting barium in
the In the stomach and
Children with clinically obvious pile orrick
hypertrophy,
it's a useful procedure because
possibly 10 12 15% of these kids may
have some atypical form of the
disease or associated congenital anomaly.
And it may not be appreciated unless the barium is
given.
And that barium is actually not going to harm anything.
The major problem with giving them barium is that it takes a
long while to get out.
And if you're standing there looking at the child,
you use your foot switch a little bit too much and
overdose the the infant so that the
easiest thing to do is to give them the barium and if it
holds up at the Uh pile or a
complex to uh go away leave them
uh and go to another
examination or put them off in a quiet room somewhere and bring them
back 30 or 45 minutes later.
And you're able to get this kind of picture with a minimal
dose to the child.
That's the most critical aspect of the
uh examination,
not the barrier.
The characteristic diagnostic criteria
of pylori stenosis and the child have
been described by
uh several people.
Uh There is of course the characteristic Antrel
beak where no filling of the canal.
Asi guest aureus occurs only this little beak like
structure at the beginning of the proximal portion of the
pie loris.
Occasionally barium may get through and
pacify the duodenal cap.
And then we have the so called beak gap and
cap.
We don't see the canal is itself just the
proximal stomach and the uh
duodenal bulb.
And uh here when barium
can get through the elongated
uh pile orrick segment.
Plus this little out patching which is
known as twinings recess.
It was first described by dr twining,
a british radiologist and represents the residual
of the la Oculus or that portion of the
stomach which bulges between the
proximal and distal loops.
As the hypertrophy of the loops becomes more prominent
and of course reduces the potential size of the lot Oculus.
And also one should look for the parallel folds when complete
contraction has occurred.
Now this is the characteristic finding the child and that's what we usually
think of in terms of pilot hypertrophy,
but the same thing can happen in the adult.
Now this is a characteristic case of pilot hypertrophy.
An adult where you have delineation of the
majority of the canal Torres,
A bulge into the base of the duodenal ball
representing the hypertrophic muscle pushing into the
base,
which was one of the first signs described by this by
doctors twining and Kirkland.
In addition to the elongation of the canal.
And if you have films that
are made with exceptionally good technique,
you may be able to see not only the elongated
canal here,
a suggestion of the la Oculus here,
the bulge into the base of the bulb,
but also the soft tissue outline of the
hypertrophy of muscle bundle seen right there.
Now,
usually adults are not symptomatic or the
symptoms that they have are
vague and analogous to peptic
ulceration.
We usually don't have signs of
obstruction,
such as we do in the child.
But remember again that this is a
tripartite muscle,
it has the Taurus and the distal and
proximal slings.
Now,
I point this out because it's important that,
you know that this muscle
can hypertrophy in part or in
whole,
we saw in the child,
that it usually is involving all portions of the
muscle.
That is not necessarily the case in the adult
here is the typical picture in the adult
with the bulge bill Oculus and the
elongated canal asi gassed aureus.
This particular appearance is
primarily of importance because this is
commonly misdiagnosed as a pile orrick channel
ulcer when indeed it represents just that little out
patching that we've talked about very
frequently.
People with this degree of hypertrophy are asymptomatic.
However,
with partial hypertrophy,
this is the sort of picture that one can expect here,
for example,
is hypertrophy of the Taurus alone
without any significant thickening of either the distal
or proximal slings.
This is reputed to be the most common type of pie
Lorik hypertrophy but found primarily at
autopsy rather than in
the living individual.
Uh It may be the most
dominant portion,
even though sling hypertrophy may
coexist.
And here's a case in point where the Taurus hypertrophy
is quite prominent and relatively little
changes seen in either the proximal or distal
slings.
Now here's an individual in whom you would have a very difficult
time in ruling out a diagnosis of
carcinoma of the stomach or possibly
granuloma of the stomach.
You notice that the pile orrick
segment here,
the distal sling is probably a little heavier than
normal,
but that's about all that can be said about it.
The entire Antrim is reduced in volume,
but of course the major finding is this highly
irregular appearance of the more proximal
portion of the Antrim.
This is the same individual with a serial a gram
following morphine stimulation of the stomach and you see
what has happened to that defect as this
stomach contracts the individual mucosal
fold straighten out until we have total
obliteration of the Antrim.
We obviously have mobility of the folds and this
does not represent infiltrating or mucosal
cancer for that matter.
The mucosa is intact.
This then is hypertrophy of the
proximal segment of the pile orrick
muscle,
plus concomitant Taurus hypertrophy
and some hypertrophy of the
muscular fibers between the proximal and
distal sling.
The distal sling itself is relatively uninvolved,
producing this very bizarre appearance.
And this has been confirmed surgically the
partial hypertrophy of the pile oric muslim.
And of course in the adult as well as in the
child,
the entire muscle can be hypertrophy,
in which case it looks exactly as the
case that I demonstrated you to you in the
infant.
Another manifestation of that same patient
showing the clearly recognizable
twinings recess.
Now let's see if we can tie
these all together a little bit.
We have such things occurring in the
Antrim in the stomach rather as
gastritis,
various inflammatory states.
We can have alterations that occur anywhere in
the stomach.
We can have pie Lorik
hypertrophy which is limited of course,
to the pile orrick segment.
Is there any relationship between these two.
Uh These these entities do do these
aid in a bet one another or are they completely separate?
And can they be considered
individually?
Well,
I've already pointed out that
probably the Antrim is involved more severely
by diffuse inflammatory processes than the
proximal portions than more proximal portions
of the stomach Secondly Insofar as
pie Lorik hypertrophy is concerned
about 50% of these people have
concomitant gastric ulceration and it's
been an argument for a long while and still going on I guess.
uh as to which came
first whether the hypertrophy is a
function of the chronic gastric
ulceration or whether the ulcer has
developed as a result of the pile Orrick.
I've heard hypertrophy,
probably the so called drag stead theory is
applicable here.
As you know,
the gastric Antrim produces gastric
and Gaston is produced in response to stimulation of
the Antrim by food.
If you have a pile orrick hypertrophy which
produces some degree of stasis of ingested
materials in the stomach,
that's going to result in prolonged stimulation of
the Antrim stimulation of the
Antrim in turn,
will produce excessive quantities of gastronomy and
Gaston of course,
is responsible for an outpouring of hydrochloric acid in
the stomach.
And this may well be the mechanism that results in
gastric ulceration.
In an individual with pile orrick hypertrophy.
It may also be the mechanism that results
in the high incidence of concomitant
gastritis in these people who have pile orrick
hypertrophy and indeed,
usually their symptoms are related either to the
ulceration or gastritis or both,
rather than the hypertrophy per se in terms of
obstruction.
Now this being the case,
it's quite possible that we're going to have inflammatory changes
superimposed upon the changes of
pylori hypertrophy.
And here's a case in point,
There's gross deformity of the Antrim.
We see these bizarre looking mucosal folds
as well as the characteristic bulge into the base of the
duodenal bulb representing the hypertrophy of muscle.
Now,
why do we see this?
It's very difficult to identify,
is there a purely inflammatory process here
is this hypertrophy with superimposed
inflammatory disease,
or is this all hypertrophy?
Probably not the latter because of this bizarre
appearance of the mucous membrane?
Well,
the histological section gives us our answer.
Here's the hypertrophy of the muscle,
but you notice that that muscle is intensely
adamis between the bundles of
fibers.
And here is an extensive sub mucosal edema.
There was also infiltration of the mucous
membrane.
This then represents an acute
gastritis superimposed upon
a pile orrick hypertrophy with the
edema of the individual
structures that we have just pointed out,
resulting in this bizarre configuration
and it's one that's very difficult to separate from cancer.
Again,
morphine stimulation is apt to be very helpful in
these individuals.
Now,
this can go on to frank obstruction and
produce the classic findings of of
pylori hypertrophy,
here's a grossly dilated stomach,
there's obviously an obstruction at the outlet.
It's impossible to tell what it is.
But here in the operative specimen again,
hypertrophy of muscle and this massive sub
mucosal edema that precipitated obstruction in this
adult with longstanding pylori
hypertrophy.
Again.
However,
actual acute obstruction is uncommon.
Now,
if it can occur in the acute
stage,
then it certainly can become chronic,
as we indicated earlier in the discussion.
When I pointed out to you this so called fibrosis natural
gastritis and it can be very difficult in that
supposed identity to make a
differentiation between pile or a
hypertrophy and superimposed
gastritis uh as opposed to
the gastritis alone.
In fact,
maybe the gastritis alone does not occur.
That's a moot point.
But be that as it may,
if you can have acute gastritis superimposed
upon pylori hypertrophy,
then you can have the chronic changes of gastritis
superimposed.
And here is a grossly elongated
canal canal,
asi gassed aureus.
No hint of a normal mucous membrane by
anybody's definition.
This could well be uh an annular
carcinoma of the distal stomach,
but on section hypertrophy of the
pile orrick muscle and diffuse sub
mucosal fibrosis resulting from chronic
inflammatory changes in the stomach,
probably secondary to uh the
hypertrophy.
So that the hypertrophy is not innocuous,
it probably gives rise to
proximal inflammatory disease and the proximal
inflammatory disease can then in turn produce
chronic changes which sets up a sort of vicious
cycle which can eventuate in
obstruction or certainly the need for
surgery if chronic ulcers are present and
so on.
From the differential diagnostic standpoint I mentioned
briefly,
just a couple of entities,
this is a so called central diaphragm
which is a congenital anomaly.
It's of no particular significance.
It does not produce obstruction in the average case,
it's just there because of its
distribution.
It could be confused with hypertrophy
of the proximal sling.
But it usually isn't because most people don't know there's a proximal
sling.
So they call it an actual diaphragm and they're right.
However,
uh it should not be mistaken and is
readily identified,
notice that it disappears with total contraction of
the Antrim.
This is just another view of it,
showing its apparent relationship
to the proximal sling and the
formulation of the la Oculus
on the on the greater curvature aspect.
This certainly simulates very closely
hypertrophy,
partial hypertrophy of the pile orrick complex.
The big differential of course,
lies in the elimination
of uh possible uh
cancer.
And this can be extremely difficult,
particularly as the mucous membrane pattern gets more and more
bizarre with superimposed inflammatory
changes.
Here is an infiltrating sub mucosal
carcinoma of the Antrim which looks for all the
world like pile oric hypertrophy.
Probably the most useful mechanisms in the
differential diagnosis are the double contrast
study,
which shows you the status of the mucous membrane
and the use of a variety of drugs
to stimulate gastric peristalsis.
The pile oric hypertrophy.
The pile or IQ
gastritis will respond
in the in most cases to the stimulation.
Not always,
there's a minority that do not but in most cases it
will respond.
Whereas of course uh the bulk
of the cancers do not
respond.
It can be very difficult.
However,
if the infiltrating cancer is largely sub
mucosal which they occasionally can be in
this particular area every once in a
while can accommodate ulceration with
the uh cancer can
simulate twinings recess and in
fact this particular patient was
diagnosed as having a pylori
pylori hypertrophy.
When actually uh this was an
ulcer rating carcinoma
in summary.
Then the
Antrim is a
complex portion of the stomach which because of
its secret o'Ryan functional activity
as well as its structural aspects shows
certain diseases and
certain findings which are not
identified in the more proximal portions of the stomach.
Once the anatomy of this area is understood,
it's not difficult to identify these
diseases with the possible exception of the
exclusion of cancer as
opposed to the advanced pile arc hypertrophy with
superimposed inflammatory disease.
Drug stimulation can be useful in this effect
in this particular area but not always.
And if there's any question in your mind the patient should
be subjected to surgery.
Unfortunately,
endoscopy frequently doesn't help because they
cannot BCC beyond the narrow portion of the
stomach.
If there is infiltration of the tumor approximately they may be
able to appreciate it.
But if it is distilled to the point of proximal narrowing
they can't see it any better than we do.
And it remains to the surgeon to
remove a piece for histological examination before the
differential diagnosis can be made.
Thank you.
A medical media production from W.
R.
E.
M.
C.
T.
V.