Pyloric Stenosis in Adults: a Clinical and Radiological Study of 100 Consecutive Patients

Gut: first published as 10.1136/gut.6.3.253 on 1 June 1965. Downloaded from Gut, 1965, 6, 253

Pyloric stenosis in adults: A clinical and radiological study of 100 consecutive patients

LOUIS KREEL' AND HAROLD ELLIS From the Departments of Radiology and Surgery, Westminster Hospital, London

EDITORIAL SYNOPSIS The causes of obstruction in 100 cases diagnosed clinically as 'pyloric stenosis' showed that the majority of cases were duodenal ulcer stenosis, with prepyloric carcinoma as second in frequency. In the earlier stages the obstruction is overcome by hyperactivity of the gastric muscle but later on muscular failure occurs with gastric atony and retention of food. This is reversible and should be corrected before surgical treatment.

This paper presents a study of a consecutive series duodenal ulcer, 36 had carcinoma involving the of 100 adult patients with pyloric stenosis, confirmed pyloric antrum, four had benign pyloric ulcers, and in every case at operation, in order to illustrate the two had adult hypertrophy. In addition one patient clinical and radiological features of this condition, had Hodgkin's disease involving the gastric outlet and to discuss the dynamic as well as the purely and another had an ectopic pancreatic nodule at anatomical aspects of the lesion. the pylorus. From the pathological point ofview the commonly used term 'pyloric stenosis' in the adult patient is TABLE I http://gut.bmj.com/ inaccurate, since the obstruction is rarely at the 100 CONSECUTIVE PYLORIC OBSTRUCTIONS pylorus itself but is situated either immediately Cause of Obstruction No. of Cases proximal to the sphincter, where the diagnosis of carcinoma is most likely, or more distally, in the Duodenal ulcer 56 Carcinoma 36 duodenal bulb, where almost invariably the cause is Pyloric ulcer 4 a duodenal ulcer. A more correct designation would Adult hypertrophy 2

Hodgkin's disease 1 on September 28, 2021 by guest. Protected copyright. be 'gastric outlet obstruction'. However, the term Ectopic pancreas 1 pyloric stenosis is so well established that it is Total 100 unlikely to be displaced, and we are certainly not suggesting gastric outlet obstruction as a substitute. CLINICAL FEATURES The criteria accepted for inclusion of patients in this series were as follows: A comparison of the 56 patients with duodenal 1 Clinically, one or more of the following ulceration and the 36 with carcinoma of the antral features: projectile vomiting (particularly if food was region is of interest (Table II). There were no noticed which had been eaten the previous day), the significant differences in average age between the presence of a gastric splash heard four hours or benign and malignant group (56 and 60 years more after the last meal, visible gastric peristalsis, respectively) nor in the age range or sex distribution or a gastric residue of 500 ml. or more. (68 % and 59% for males respectively). 2 Radiologically, all patients had definite evidence of gastric outlet obstruction, which will be TABLE II discussed later. Duodenal Ulcer Carcinoma 3 In the of organic 'pyloric' all cases diagnosis Male 38 (68%) 21 (58%) narrowing was confirmed at operation. Female 18 15 The causes of the pyloric stenosis in this series Average age (yr.) 56 60 were as follows (Table I). Fifty-six patients had PAIN of of indigestion and 'Present address: Department of Radiology, The Royal Free Hospital, The length history Gray's Inn Road, London, W.C.1. epigastric pain, not unnaturally, tended to be 253 Gut: first published as 10.1136/gut.6.3.253 on 1 June 1965. Downloaded from 254 Louis Kreel and Harold Ellis considerably longer in the patients with benign EXAMINATION ulcers (Table III). It is interesting, however, that five patients with duodenal ulceration had a history of On clinical examination it is obvious that the pain for less than one year. One of these patients 'typical ulcer facies' of the old text books applied to with a history of only two months had had a previous many of the duodenal ulcer patients with stenosis. thoraco-lumbar sympathectomy for hypertension Thirty-three patients were thin (59 %) and only one and may well have had a consequent gastric denerv- of the whole group was described as obese. Abdom- ation. Of the remaining duodenal ulcer patients, inal examination revealed a splash in 36 patients of 11 had a history of one to four years, 12 of five to the ulcer group (64 %), in nine of whom, in addition, nine years, and 27 had a history of from 10 to 20 visible peristalsis was seen and in four of whom the or more years; in one patient the length of history gastric distension was great enough to produce a was not recorded. large, palpable mass. In contrast, only five of the In contrast, 11 of the 36 patients with carcinoma patients with carcinoma had a splash (14%) and had experienced no pain at any time, in 20 the only one had visible peristalsis. However, 19 of the history was under one year, in three the history was patients with carcinoma had a palpable mass in the up to two years, one was of three years' duration, pyloric region (Table IV). and in one patient there had been mild dyspepsia for the preceding eight years. TABLE IV Duodenal Ulcer Carcinoma TABLE III Mass 19 (53%) LENGTH OF HISTORY OF PAIN Splash 36 (64%) 5 (14 %) Duodenal Ulcer Carcinoma Stomach visible 9 1 Stomach palpable 4 Under 1 year 5 20 1-4 years 11 4 BIOCHEMICAL CHANGES 5-9 years 12 1 10-19 years 23 20+ 4 Biochemical disturbances did not occur in patients 1 who had never vomited or in whom the vomiting No pain 11 was not or of almost occurrence. In profuse daily http://gut.bmj.com/ Totals 56 36 44 patients in this series, vomiting had been copious VOMITING Vomiting was the commonest presenting and frequent before admission; in 20 of these the symptom in both groups. In the peptic ulcer patients blood biochemistry was completely normal, and in a it occurred in 49 of the 56 cases (87-5 %) and was further 11 there was only a raised blood urea above typical projectile vomiting of large amounts in 39 50 mg. % as the sole biochemical abnormality, in of these. In addition, 24 of the patients noted stale six being above 100 mg. % and in one of these food in the vomitus. In the carcinoma group 31 of reaching 243 mg. %. All were rapidly corrected after the 38 patients (86%) had been vomiting; in 23 of rehydration. In the remaining 13 patients there were on September 28, 2021 by guest. Protected copyright. them it was typical of stenosis and in nine stale food more widespread biochemical alterations including, had been noted in addition. in nine of these, a raised blood urea. In these 13 cases there were one or more of the following OTHER SYMPTOMS Weight loss was a prominent changes: sodium less than 135 mEq. %, potassium feature in both groups, occurring in 44 of the less than 3-5 mEq. %, chloride less than 95 mEq. % duodenal ulcer patients (78 %) and in 34 patients with or bicarbonate above 30 mEq. % (Table V). cancer (94 %). It is interesting that only five of the 24 patients Recent constipation was recorded in 14 of the with biochemical disturbance were admitted in a duodenal ulcer and in 12 of the carcinoma group. clinically obvious state of electrolytic imbalance- Recent diarrhoea was recorded in three of the ill, dehydrated, weak and, in one case, with obvious ulcer and in three of the cancer series. tetany. Gastrointestinal bleeding had occurred recently Anaemia (haemoglobin of less than 80%) was in five patients with duodenal ulcer and at some present in 11 of the 56 patients with duodenal time in the past in eight further cases. ulceration and in seven of the 36 with carcinoma: In the carcinoma group eight patients had small in one of the latter it was the presenting feature. recent haemorrhages; one indeed presented with melaena and another with anaemia. ASSOCIATED BENIGN GASTRIC ULCER Three of the ulcer series had perforations repaired in the past but there was no case of associated Four of the patients with duodenal ulceration had perforation in the cancer group. an associated benign gastric ulcer confirmed at Gut: first published as 10.1136/gut.6.3.253 on 1 June 1965. Downloaded from Pyloric stenosis in adults: A clinical and radiological study of 100 consecutive patients 255 TABLE V PATIENTS WITH BIOCHEMICAL DISTURB 'NCES' No. Diagnosis Vomiting and its Duration Na K Cl Biicarbon- Urea Clinical State (mEq./l.) (mEq./l.) (mEq./l.) ctte (mEq./l.) (rnnEq.!l.) Duodenal ulcer Large amounts, 3 mth. 146 3-1 82 34 57 Satisfactory 2 Duodenal ulcer Large amounts, 3 mth. 132 3-2 89 35 61 Satisfactory 3 Duodenal ulcer Large amounts, 2 mth. 136 3-7 80 31 58 Satisfactory 4 Duodenal ulcer Large amounts, 2 yr. 128 4-1 128 30 17 Satisfactory 5 Duodenal ulcer Large amounts, 2 mth. 126 3-4 97 83 Satisfactory 6 Duodenal ulcer Large amounts, I mth. 142 3-4 75 50 106 Satisfactory 7 Duodenal ulcer Large amounts, 5 mth. 140 3-2 78 45 33 Satisfactory 8 Duodenal ulcer Large amounts, 6 mth. 145 3-8 45 64 243 Dehydrated, tetanic 9 irrational, Duodenal ulcer Large amounts, 1 mth. 132 2-9 87 39 119 Thin, ill, dehydrated 10 Duodenal ulcer Large amounts, I yr. 148 3-2 89 37 Ill, dehydrated 1 I Carcinoma Large amounts, 1 mth. 124 2-8 75 104 111, dehydrated 12 Carcinoma Large amounts, 2 mth. 137 29 80 245 lll, dehydrated 13 Gastric ulcer Large amounts, 4 mth. 131 50 91 27 Satisfactory 'Other than raised blood urea onlly operation. Three of these were women. Two more patients, also women, had radiological evidence of a gastric ulcer, although as these patients had drainage procedures and not partial gastrectomy, histological confirmation was not obtained. Apart from this quite marked sex bias for gastric ulcer associated with stenosis due to duodenal ulcer, analysis revealed no relevant differences from the remaining patients with benign pyloric obstruction. http://gut.bmj.com/ RADIOLOGICAL AND BARIUM MEAL EXAMINATION

The radiological signs of pyloric stenosis can be divided into those indicating the presence of obstruction at the gastric outlet and those indicating its site and possible nature. However, very un- commonly, the first radiological abnormality to be detected is the presence of lymphangitis carcinoma- on September 28, 2021 by guest. Protected copyright. tosa on the chest film (one case). Occasionally there is evidence of gastric stasis on the plain film of the abdomen in the form of a large gastric shadow with retained food particles producing patchy translucencies (two cases). In these cases an erect film will show a large, high gastric fluid level. Retention of oral cholecystographic contrast from FIG. 1. Oral cholecystographic contrast medium retained the previous evening with a 'non-functioning' gall in the stomach 14 hours after ingestion of the tablets. In bladder was the first radiological evidence of two cases in this series this was the first radiological sign obstruction at the gastric outlet in two cases (Fig. 1). ofgastric outlet obstruction. Subsequent barium meal examination revealed a deformed, contracted duodenal cap as the cause of descending along the lesser curve and parting the the obstruction. opposed gastric walls, the blobs of barium sink through a layer of fluid and come to rest at the SIGNS OF OBSTRUCTION AT THE GASTRIC OUTLET bottom of the greater curve giving a saucer-like There are several signs of obstruction at the gastric appearance. Thus the film in the erect position shows outlet visible radiologically. three media: air, resting juice, and barium, with two Presence of excessive fasting gastric juice This is intermediate fluid levels (Fig. 2). immediately apparent on the first mouthful of Excessive peristalsis While the stomach is in the barium reaching the stomach. Instead of the bolus 'compensated' phase, it shows two to three giant Gut: first published as 10.1136/gut.6.3.253 on 1 June 1965. Downloaded from 256 Louis Kreel and Harold Ellis Delay in emptying A 24-hour barium residue is usually diagnostic but this is seldom necessary. A four to six-hour film, using barium sulphate as the contrast medium, normally shows less than 20% retention whereas in pyloric stenosis there is more than 50 % retention. It is, however, important to exclude pylorospasm or obstructive lesions in the proximal small bowel. Pylorospasm can be distin- guished by administering probanthine intravenously, after which the stomach will empty normally. http://gut.bmj.com/

FIG. 2. Barium entering the stomach in the presence of excessive gastric juice showing three media barium, gastric juice, and air-and the two intervening fluid levels. peristaltic waves which indent both the greater and lesser curves simultaneously. These giant waves serve to distinguish the large active stomach of FIG. 3. Giant peristaltic waves in the 'compensated' on September 28, 2021 by guest. Protected copyright. pyloric stenosis from the obstructed atonic organ phase ofpyloric obstruction which, in this case, is due to (Fig. 3). duodenal scarring with an associated penetrating ulcer. However, in the phase of failing compensation At this stage no barium was present at six hours. Four these peristaltic waves peter out after a variable months later this patient was re-admitted in the 'decom- period (one to three hours) leaving an atonic pensated' phase with a large atonic stomach. stomach. It thus not infrequently occurs that there is good emptying through the area of stenosis Obstructive lesions in the second and third parts initially, and yet a significant barium residue is of the duodenum or in the proximal part of the present in the stomach at four to six hours. The jejunum may show all the radiological and clinical presence of giant peristaltic waves is thus an indica- features of pyloric stenosis. tion that a delayed film must be taken to assess the Abnormal mobility of the pylorus Where the site barium residue. of obstruction is beyond the pylorus, as in cicatriz- Large atonic stomach The large atonic stomach ation of the duodenal cap, the pyloric canal shows is found in both gastric outlet obstruction and in abnormal mobility. The pyloric canal may dilate functional stasis. However, in the latter condition intermittently, up to 2-5 cm. in width, and thus barium flows freely through the pylorus if the appear to be part of the gastric antrum, but further patient is correctly postured, i.e., prone with the observation will show it to contract down to its left side raised. The large stomach is more common usual size. This abnormal dilatation (Fig. 4) of the with benign than with malignant lesions as has been pyloric canal, we have found, is a reliable sign of noted under clinical features above. duodenal bulb obstruction and could be demon- Gut: first published as 10.1136/gut.6.3.253 on 1 June 1965. Downloaded from Pyloric stenosis in adults: A clinical and radiological study of 100 consecutive patients 257 ing mural lesion. The margins of the tapered antrum tend to be irregular and the wall is rigid. It can only be moved in toto, if at all, and does not indent on palpation. Moreover there is a lack of peristalsis, so that films taken at various intervals can be accurately superimposed. The superior margin of the rigid, rounded antrum (two cases) is often irregular and again accurate superimposition of successive films is possible (Fig. 5). A filling defect within the antrum, due to the carcinoma, may be detected on gentle pressure. An antral mass with destruction of the mucosal pattern was found in 18 cases. A large irregular

PYLORIC CANAL

STRICTURE IN MID-DUODENUM

FIG. 4. Two adjacent spot films from a serial showing abnormal 'dilatability' of the pylorus proximal to a stricture ofthe mid-duodenal bulb. http://gut.bmj.com/

strated in almost all patients (50 of 56 cases). This appearance may also occur, but to lesser extent, in obstructive lesions elsewhere in the duodenum, e.g., arterio-mesenteric occlusion, or carcinoma of the duodenum. on September 28, 2021 by guest. Protected copyright. SIGNS INDICATING THE SITE AND NATURE OF OBSTRUC- TION The cause of obstruction at the gastric antrum is almost always malignancy although obstruction may rarely be caused by cicatrization from peptic ulcer, corrosives, or chronic inflammatory lesions such as tuberculosis and syphilis. Occasionally the malignant process arises outside the stomach as in pancreatic carcinoma or in Hodgkin's disease of the FIG. 5. Three superimposed exposures on one filnm to abdominal lymph nodes. demonstrate the rigidity of the gastric antrum compared The radiological signs of malignancy are the with the mobility elsewhere. The filling defect of the rigidity of the antral wall, its lack of peristalsis, and carcinoma can be seen in the antrum. its irregular contour. The rigidity is indicated by its lack of movement on positioning and on palpation. Successive films can be superimposed with accuracy, filling defect, usually arising from the greater curve, accounting for the 'rigid' quality seen on films. The may cause obstruction at the gastric outlet. There is irregular contour often affects the superior margin of usually little doubt about this appearance being the antrum and may be associated with the absence malignant, but just occasionally the granulation of the mucosal pattern. tissue surrounding a penetrating posterior wall The tapered antrum (14 cases) may be produced gastric ulcer produces similar appearances, including by a mass surrounding the antrum or by an infiltrat- the absence of a mucosal pattern (Fig. 6). 258 Louis Kreel and Harold Ellis Gut: first published as 10.1136/gut.6.3.253 on 1 June 1965. Downloaded from i _ A carcinomatous ulcer may be associated with obstruction of the gastric outlet. Recurrence around a gastric stump following gastrectomy produces appearances similar to the tapered antrum above but now at the gastric stump outlet. (One case, which is not included in this series, was seen.) Lesions occurring at the pyloric canal may produce obstruction, but this is in fact, the least common site of obstruction of the gastric outlet. Obstructive symptoms and signs may appear in the presence of active ulceration, when a persistent barium fleck or ulcer niche will be visible. More commonly, the obstruction occurs following cicatrization. The canal is then narrowed and elongated. In this respect it is important to note that the diameter ofthe canal does not correspond to the width between the barium streaks in the pyloric canal (Fig. 7) as was shown by Williams (1962). We include four cases in this series. Adult hypertrophic pyloric stenosis (two cases) can be recognized by the bulbous intrusion into the base of the cap, the spikes along the canal, and the length of the narrowed segment. Occasionally the impression on the base of the cap is so marked as to produce a circular filling defect in the duodenal bulb (Fig. 8). FIG. 6. A benign posterior wall gastric ulcer with excessive granulation tissue mimickiing a carcinoma of the http://gut.bmj.com/ antrum by producing a large fill'ing defect on the greater - curve with associated obstruction. on September 28, 2021 by guest. Protected copyright.

FIG. 7a. A radiograph of the cloosed pylorus, the mucosal furrows in the pyloric ring tra,pping barium to give a picture of white lines. FIG. 7b. The slit lumen of the pylorus is asymmetrical. The distance between the barium streaks will depend on the direction of the rays FIG. 8. Film of adult hypertrophic pyloric stenosis in and does not which the impression on the base of cap by the hyper- correspond to the trophied pylorus was so marked as to produce a circular diameter of the canal. filling defect in the duodenal bulb. Pyloric stenosis in adults: A clinical and radiological study of 100 consecutive patients 259 Gut: first published as 10.1136/gut.6.3.253 on 1 June 1965. Downloaded from

Although ectopic pancreatic tissue may occur in curve wall with the lower fornix forming the the antrum and duodenum it seldom causes obstruc- prestenotic diverticulum of Akerlund. This was the tion. However, if it is situated at the pylorus this most common appearance in our series (36 cases). may occur. The clue to its presence lies in the demon- 2 Central scarring producing a dumb-bell stration of a thin streak of barium communicating appearance (three cases). with the pyloric lumen. This represents barium in 3 Central scarring forming an irergular star- the duct of the ectopic pancreas (Fig. 9). One case shaped configuration (nine cases). is included. 4 Pyloric stenosis caused by peptic ulceration is Scarring of the duodenal cap may take one of often associated with active ulceration. In the several forms, but our cases have fallen into the duodenum the ulcer is often of the penetrating type following groups: producing the appearance of an 'irregular diverti- 1 Eccentric scarring of the superior or lesser culum', which tends to remain constant in size and

FIG. 9. Obstruction caused by heterotopic pancreatic tissue encircling the pyloric canal. Note the barium streak outlining the ectopic pancreatic duct. http://gut.bmj.com/ on September 28, 2021 by guest. Protected copyright. Gut: first published as 10.1136/gut.6.3.253 on 1 June 1965. Downloaded from 260 Louis Kreel and Harold Ellis position and most frequently occurs on the postero- sufficient residue in the stomach for a gastric splash superior aspect of the duodenum. At operation it is to be elicited; as the stomach hypertrophies visible frequently associated with adherence of the duo- gastric peristalsis may be seen; finally the thickened denum to the liver or the pancreas by a mass of stomach, full of inspissated contents, becomes granulation tissue. palpable. 5 As previously mentioned an associated gastric In contrast, the length of history in gastric ulcer was present in six of 56 patients with duodenal carcinoma is usually short and indeed in about one- ulceration. third of cases there is no story of abdominal pain at all. The short period of obstruction does not allow DISCUSSION gastric hypertrophy to take place and even the presence of a gastric splash in these cases is unusual. AWARENESS OF EARLY DIAGNOSIS The diagnosis of On the other hand careful palpation will often reveal established pyloric stenosis is not a difficult one to the presence of an abdominal mass in the region of make; there are the typical features of projectile the pylorus. The detection of such a mass is not vomiting, the presence in the vomitus of food eaten entirely diagnostic of tumour. Rarely one finds that one or more days previously, loss of weight, and the thickening and inflammation around the duo- loss of appetite. On examination a gastric splash is denum and pancreatic head in the presence of a large present and there is a considerable fasting residue active ulcer may produce a very similar mass; we on gastric aspiration. However, the clinician should have seen two such examples, although none was be aware of the fact that the chronic duodenal ulcer, present in this series of cases. as it gradually constricts the gastric outlet with scar To summarize, the patient with the typical tissue, may produce gross obstruction without features of a duodenal ulcer which progresses to vomiting ever having occurred; this was so in seven pyloric stenosis will clinically have a long history, patients with duodenal ulcer in this study (22 5 %). show marked loss of weight, and a gastric splash It is easy enough to miss this change in the character will be present. The patient with carcinoma will of a patient's pathology unless a careful examination typically have a relatively short history, may in fact is carried out at each attendance. The presence of a have experienced no pain at all, and will frequently gastric splash several hours after the last meal is an demonstrate an abdominal mass without evidence important sign and may occur without the presence of gross dilatation. http://gut.bmj.com/ of any warning symptoms. The pre-operative diagnosis of the rarer conditions producing stenosis is usually only possible PATHOLOGY AND DIFFERENTIAL DIAGNOSIS As is radiologically and even then may not be accurate. seen in Table I, duodenal ulcer is the commonest The surgeon must therefore be aware of these cause of pyloric obstruction, followed by pyloric unusual causes when called upon to perform a carcinoma. Other causes are all rare; these include laparotomy on a patient with pyloric obstruction.

pyloric gastric ulcer, benign pyloric hypertrophy, There are few radiologists who routinely take on September 28, 2021 by guest. Protected copyright. heterotopic pancreatic tissue, and the pressure of four to six-hour films or 24-hour films after a barium enlarged adjacent lymph nodes. All these are meal. If patients with abnormal gastric stasis are represented in the present series. Other unusual not to be missed, one must be aware of those signs causes are scarring due to a chronically inflamed gall which may indicate the presence of obstruction of bladder, annular pancreas, congenital partial duo- the gastric outlet. Excessive resting gastric juice, denal diaphragm, the prolapse of a gastric polypus excessive dilatability of the pyloric canal and giant through the pylorus, chemical strictures, eosino- peristaltic waves, singly or in combination, call for philic granuloma, and extrinsic fibrous adhesions. a delayed film to assess barium retention. The differential diagnosis between the two common However, an obstructive lesion may be present conditions of duodenal ulcer and carcinoma can with normal emptying of the stomach and a normal often be made clinically with some degree of four to six-hour barium residue in the presence of accuracy. In the case of duodenal ulceration the giant peristaltic waves. This has been called the process is usually a long one and the history of 'compensated' phase of pyloric stenosis (Shanks and dyspepsia in two-thirds of the patients in this series Kerley, 1958). This excessive gastric peristalsis leads was five or more years. The long-standing stenosis to muscular hypertrophy and thickening of the enables the stomach to dilate and hypertrophy and stomach wall, as was frequently confirmed at opera- this was summarized in the aphorism of the late Sir tion. This hypertrophy not infrequently extends to James Walton, who described successively 'the include the lower oesophagus. This may on occasion stomach one can hear, the stomach one can see, be recognized radiologically. and the stomach one can feel'. At first there is In patients with benign lesions such as duodenal Gut: first published as 10.1136/gut.6.3.253 on 1 June 1965. Downloaded from Pyloric stenosis in adults: A clinical and radiological study of 100 consecutive patients 261 ulcer scarring and adult hypertrophic pyloric the dilated stomach with its secondary gastritis is a stenosis, the exit channel may be extremely narrow dangerous organ upon which to operate. The value and yet there may be little or no gastric retention. of pre-operative diagnosis is that this enables the Gastric 'failure' leading to the onset of marked surgeon to prepare his patient carefully by gastric retention of gastric juice, and food residue is thus washouts, fluid and electrolyte replacement, and a not entirely dependent on the degree of obstruction. strict medical ulcer regime. This will result in a The high incidence of associated penetrating ulcers considerable improvement both in the general in the duodenal ulcer cases suggests that reactivation condition of the patient and in the tone of the of the ulcer may be a precipitating factor. stomach wall. As the active ulcer heals and the Gastric muscle failure may occur as a conse- surrounding oedema diminishes, the condition quence of this overactivity, the giant peristaltic reverts to the compensated phase in which the motor waves petering out before the stomach is entirely power of the stomach is able to overcome the empty. The gastric residue then builds up, and is pyloric obstruction once more. not relieved even by a night's rest. The fasting It may be that enthusiasm on the part of the 'gastric' juice under these circumstances may indeed clinician may result in occasional diagnoses of be largely due to swallowed saliva. We have, organic pyloric obstruction being made when in unfortunately, not been able to devise a method for fact this condition does not exist. This may happen, separating swallowed saliva from gastric secretion for example, in the presence of a duodenal ulcer and thus to tell whether the fasting 'gastric' juice with marked pylorospasm without actual organic originates mainly in the mouth or in the stomach. stenosis or in an atonic stomach with the presence It may indeed be that the decompensated phase of a gastric ulcer remote from the duodenum. In of pyloric stenosis, with gastric atony and marked other cases excessive vomiting with loss of potassium gastric retention, is caused by an inherent muscular may result in temporary gastric atony which may failure, dependent on intracellular potassium or simulate stenosis. These possibilities are not magnesium transference. In this respect the gastric common; there are usually in any case other indica- muscle failure may be similar to cardiac muscle tions for surgical intervention and it is safer for the decompensation in stenotic valvular heart disease. surgeon to err on the side of too frequent rather The ultimate cause of the gastric muscle failure than too infrequent diagnosis of this condition. or atony in pyloric stenosis is obscure, but it is http://gut.bmj.com/ clear that most patients are diagnosed long before We should like to thank the physicians, surgeons, and this late stage in the disease is reached. radiologists at the Westminster Hospital who allowed us free access to their notes and radiographs. THE IMPORTANCE OF DIAGNOSIS The diagnosis of Our thanks are also due to the Photographic Depart- pyloric stenosis is an absolute indication that ment of the Royal Free Hospital for preparing the surgical exploration of the abdomen is required. It reproductions. is important that the clinician and radiologist REFERENCES on September 28, 2021 by guest. Protected copyright. establish the diagnosis pre-operatively. Metabolic Shanks, S. C., and Kerley, P. J. (1958). A text-book of X-ray diagnosis, disturbances may be present which will require 3rd ed., vol. 3, p. 128. H. K. Lewis, London. careful correction before operation, and moreover Williams, I. (1962). Closure ofthe pylorus. Brit. J. Radiol., 35, 653-670.