Overview.
Adult hypertrophic pyloric stenosis is a narrowing of the pyloric canal caused by hypertrophy of the pyloric annulus. It is characterized by periodic vomiting since infancy and epigastric discomfort and dyspepsia in adulthood, with common symptoms such as increased pain with vomiting after eating, and bleeding in middle-aged and older adults. It is relatively insidious, and should be considered when there are stenotic changes in the distal stomach, which is rare in the clinic. 80% of the cases are male patients, and the age of onset varies greatly. The detection rate of routine gastric barium meal imaging is only 0.04% to 1% in some cases. It is associated with congenital hypertrophic pyloric stenosis, which is not uncommon, accounting for 0.25% to 0.5% of births, and often presents with symptoms 3 to 12 weeks after birth.
Etiology
The etiology of hypertrophic pyloric stenosis in adults is not well understood and is generally divided into two categories, primary and secondary. most of the cases reported in the first half of the 20th century were secondary to gastric ulcers, duodenal jugular ulcers, a history of cancer or postoperative adhesions, and gastric stones, and were associated with prolonged spasm of the pyloric sphincter due to localized inflammation, ulceration, and so forth. It is thought to be a continuation of infantile hypertrophic stenosis, with a history of postnatal vomiting and surgery in 20% of cases. Primary cases are rare, and are mostly a continuation of congenital hypertrophic pyloric stenosis, which has no obvious gastrointestinal symptoms after birth and often manifests itself in adulthood.
Symptoms.
There are 3 types:
1. with epigastric discomfort and periodic vomiting from infancy, i.e., intermittent manifestations of pyloric dysfunction from infancy and childhood until entering adulthood. However, some primary cases do not have a history of recurrent vomiting in infancy.
2. It is only in adulthood that epigastric discomfort and dyspepsia begin to appear, with the most common symptom being increased pain and vomiting after eating.
3. Symptoms of pyloric obstruction appear only in middle-aged and elderly people, and the history of ulceration is shorter, but progressive and may be accompanied by bleeding. After detailed examination, the final surgery only revealed pyloric muscle hypertrophy.
Clinical symptoms are related to the degree of pyloric stenosis and the duration of the disease, or may be asymptomatic. Symptoms usually appear in adulthood and are characterized by postprandial epigastric fullness and discomfort or postprandial vomiting, which is followed by intermittent episodes of relief of epigastric discomfort. Pre-pyloric ulcers are often associated with these symptoms. Signs are rare, and the hypertrophied pyloric canal is rarely palpable; in severe cases, there may be signs of pyloric obstruction.
Examination
1. Laboratory examination
Histologic examination can clarify the diagnosis.
2. Other auxiliary examinations
Gastroscopy and barium X-ray meal are commonly used. Gastroscopy shows gastritis changes, ulceration of the anterior pyloric region, obvious narrowing of the pylorus when there is obstruction, and smooth edges.X-ray barium meal contrast shows that the pyloric canal is long and narrow, and there are small triangular pouch-like bumps on one side or both sides of the middle section, which can disappear after localized pressure is applied. The mucosal folds of the lumen are usually arranged in longitudinal rows, and sometimes they are curved and irregular. A crescent-shaped indentation appears at the base of the duodenal jugular abdomen, which is caused by part of the hypertrophied pylorus snapping in.
Diagnosis
The diagnosis of this disease is difficult, if the clinical manifestations of this disease should be further examination to clarify. Gastric fluid retention is often increased, and gastric acid secretion is mostly normal. Gastroscopy and barium X-ray can help diagnosis. Confirmation of the diagnosis depends on pathologic and histologic examination.
Differential diagnosis
This disease needs to be differentiated from pyloric spasm, duodenal obstruction, pancreatic achalasia, gastric torsion and other non-obstructive vomiting.
Complications
Pyloric obstruction, gastric ulcer, mucosal erosion, bleeding, and carcinoma may be present.
Treatment
Conservative medical treatment such as antisecretory drugs can be given to those with insignificant symptoms, while most cases require surgical exploration to confirm the diagnosis and provide appropriate treatment. The effect of pyloromyotomy is uncertain and technically difficult, limited gastrectomy followed by gastrojejunostomy or gastroduodenal anastomosis is more appropriate.
Prognosis
Due to the small number of cases, there is no uniform conclusion at present.
Prevention
Prevention is particularly important if the cause is secondary, e.g. localized inflammation of the stomach, ulcers, etc.