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.