PEPTIC DISSECTION OF THE PYLORUS
DR. NILO ARTURO RAMOS ROJAS
PHYSICIAN AND SURGEAN
SPECIALIST IN SURGERY, LAPAROSCOPY, UPPER AND LOWER DIGESTIVE ENDOSCOPY
Definition of terms:
Division in parts of a plant or an animal's dead body for the examination of its normal structure or its organic alterations.
Derived from the enzyme called pepsin.
(Biochem.) Ferment segregated by the gastric glands which is capable of digesting albuminoidal substances (similar to albumin).
(Anat.) Opening from the stomach to the intestine surrounded by a thick band of circular muscle; it corresponds to mammals, birds, reptiles and batrachians.
(Derm. Pathol.) A cavity with substance loss of the skin or mucosa, for example, varicose ulcer, bedsore pressure sore, duodenal ulcer.
(Digestive Pathol. and Hepatol.) Stomach inflammation.
Morphology: the stomach is formed by the following layers:
Inner layer or mucosa: it consists on longitudinal folds that are more prominent in the fundus and the body where they have most of the secretory activity to diminish through the pyloric antrum. The main http://www.monografias.com/trabajos7/mafu/mafu.shtml"">function is secretory; in the cardia it produces mucus, and in the fundus and body there are mixed glands with a great quantity of parietal cells that produce hydrochloric acid and intrinsic factor. Also, there are cells that are the main producers of pepsinogen and foam cells that produce mucus. In the pyloric antrum there are foam cells and approximately ten million "G" cells that produce gastrine settled in the submucosa.
Middle layer: it is formed by three tunicas of muscular fibers that are arranged as: inner oblique, middle circular and outer longitudinal of smooth muscle, taking a special disposition in the cardia and the pyloric antrum similar to sphincters.
Outer layer or serosa: it corresponds to the visceral peritoneum covering both faces except the proximal part of the back face and the esophagus. On the edges it extends in the epiploons.
Gastric and duodenal ulcers and gastritis are diseases of a multifactorial origin in which aggressive and protective factors intervene. In a normal stomach there exists a balance between both factors, giving as a result the respect in the integrity of the gastric and duodenal mucosa. When there is a predominance of the aggressive factors, the integrity of the mucosa is affected and gastritis, in its different stages, occurs. Then the ulcer, the perforation of the ulcer and the consequent risk of death take place.
The perforation of the peritoneal cavity occurs between the 2% and 5% of the patients that suffer from gastric or duodenal ulcers; this is a surgical emergency that requires transportation of the patient to the operation room. If they are not treated properly they continue their progressive and typical course until the patient dies, which usually happens two or three day after the perforation.
The patient is a 62 year-old male, car dealer and without relevant pathological antecedents. He comes to the consult due to abdominal pain of several months of evolution with characteristics of pain with burning sensation. In the last two weeks the pain has increased; therefore, he looks for help. During physical examination the patient is found to have pain facies and the abdomen is soft depressible with pain in the pyloric area. A gastroscopy is performed and the following is discovered:
1. Elevation of the gastroesophageal dentate line
2. Multiple gastric ulcers
3. Perforated prepyloric fold to the duodenum
4. Gastric mitosis is discarded
Photo by Dr. Nilo Arturo Ramos Rojas
Biopsies of the major injury are taken, ant they report:
1. Moderate active chronic gastritis associated to incomplete intestinal metaplasia in 50% of the sample (Group I, according to Japanese classification)
2. Helicobacter Pylori (+/+++)
3. Negative on neoplasia
It was investigated in medical literature and it has been impossible to find a case like this one in which a peptic ulcer perforates through the duodenal bulb. Some readers would ask if a duodenal ulcer was the one that perforated the gastric cavity. According to logic and the presence of aggressive and protective factors it is indicated that the perforation or peptic dissection of the pylorus occurred from the gastric cavity to the duodenal bulb.
Photo by Dr. Nilo Arturo Ramos Rojas
As it can be observed in the previous picture, the fold is found between both orifices, the pylorus in the lower part and the upper perforation maintain the thickness and morphology of the pyloric muscle; in that way, the peptic ulcer dissected the pyloric sphincter.
Usually doctors find gastric or duodenal ulcers that perforate the peritoneal cavity or that penetrate the pancreas. What is interesting in this case is that the peptic ulcer dissected the pyloric muscle in its superior border (Photo 2) while maintaining its morphological and functional integrity.
The pylorus dissection was located in the inferior margin of the pyloric sphincter; in that way, the superior orifices observed in photos 1 and 2 are actually inferior in the endoscopy. Thus, this would indicate that the external wall of the duodenal bulb worked as a retaining wall for the ulcer perforation and the ulcer continued penetrating the different walls of the duodenal bulb until it accommodated in that portion of the duodenum.
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