Oscar M. Laudanno
It is defined as such a condition characterized by vomiting, generally food, never bilious, containing food ingested more than 12 hours before, usually several days, accompanied or not by marked dehydration and weight loss. In general, the so-called retentionist vomiting occurs in the adult subject, in which it is possible to verify the type of food and the timing of its ingestion. On the other hand, the infant, from the first days of birth, begins with frequent regurgitation of milk until around fifteen days of life, when the pyloric syndrome is already installed, presents marked regurgitations of milk that progressively lead to dehydration and obvious weight loss. Other times the pyloric syndrome does not set in gradually but rather abruptly, with epigastralgia and intense incoercible vomiting, generally mucous and acidic, without bile; it is an acute pyloric obstruction.
The concept of pyloric syndrome is conventional, since the different causes can be present in the regions of the antrum, the pylorus or the duodenum, above the ampulla of Vater; Furthermore, such etiologies can be localized in the lumen and in the wall, or act by compression or extrinsic invasion of the anthropiloroduodenal region.
In the infant the congenital hypertrophy of the pylorus, produced by a marked hypertrophy and hyperplasia of the muscular layer, is never total; in other words, something passes through the pylorus, configuring an incomplete syndrome. The diagnosis is easily made with a serial gastroduodenal radiograph, where an atonic stomach will be observed; an injection of metoclopramide will allow to visualize a fine and elongated pylorus that can become palpable as a true bun.
A foreign body (expensive, hairy, coins, etc.) can be impacted in the pyloric canal and cause a pyloric syndrome, with epigastric pain and vomiting that will be at first nutritional, and then mucous or acidic. In general, these pictures of acute pyloric syndrome disappear spontaneously, due to the progression of the foreign body or eventually its elimination with vomiting. Direct abdominal radiography or fluoroscopy, when the foreign body is metallic, clarifies the diagnosis. If spontaneous elimination does not occur, a gastrofibroscopy is indicated.
This same picture of acute pyloric obstruction in adults is described in case of: pyloric impaction or in the duodenal bulb of a polyp of the gastric antrum with long pedicle; rarely in protrusion of the antrobulbar mucosa, and in particular in Bouveret's syndrome, due to impaction of a large gallstone in the duodenal bulb, in a patient with a cholecystoduodenal fistula. The polyp with its long pedicle acts as a slap that obstructs and unclogs; in other words, an intermittent pyloric syndrome occurs. In contrast, the calculus embedded in the duodenal bulb is exceptionally detached. These patients have a known biliary history, with previous hepatic colic and episodes of cholecystitis; hence the cholecystoduodenal fistula, where the calculus passed. The diagnosis is made by a direct abdominal X-ray that will show the calcified calculus or air in the main bile ducts; It may be necessary to perform a gastrofibroscopy to directly visualize the stone.
The two most frequent causes of pyloric syndrome in adults are ulcer of the duodenal bulb or pyloric and anthropiloric cancer. Generally, it is a chronic ulcerative duodenal bulb, trebolado, where a new ulcer, accompanied by intense edema, makes it difficult and almost totally closes the light of the same one; exceptionally, an ulcer of the pilora produces a pyloric syndrome.
Pyloric syndrome due to duodenal ulcer is characteristic; This is a patient who has a past ulcer, undergoing treatment for several years, with previous studies demonstrating its existence, who again attends the consultation for epigastralgias, similar to the previous ones. The patient usually already self-medicates with little improvement, and the most striking thing is the appearance of acidic food vomits, which were progressively increasing, with marked halitosis and constipation, with the general condition and appetite preserved and a fairly stable weight. In general, intense epigastric pain and retentionist vomiting are the reason for consultation. The diagnosis is established by means of a serial gastroduodenal radiograph with double contrast, which will generally show an atonic stomach, basin type; a metocloparin injection will allow the barium to pass with difficulty through the pylorus or duodenal bulb; Sometimes an ulcer lesion may be detected in the deformed bulb.
The second cause of adult pyloric syndrome is gastric cancer of the antrum that invades the pylorus. The picture of this patient is easily differentiated from the pyloric syndrome due to duodenal ulcer since there is no ulcer past, nor pain in the epigastrium, but in general the neoclassical symptoms predominate: anorexia, food reluctance, indisgetion, asthenia and progressive weight loss . Subsequently, retentionist, non-acidic vomiting and marked halitosis are added. Physical examination may show signs, such as a palpable epigastric tumor, nodular hepatomegaly, a Troisier node, or a chronic anemic syndrome. The diagnosis is made by the gastroduodenal series with double contrast, which will show an atonic stomach with a rigid and narrowed antrum;
The pyloric syndrome due to anthropiloric cancer can be confused with another increasingly frequent cancer, pancreatic carcinoma that invades the antrogastric and often presents the same symptoms, with a neoplastic syndrome and retentionist vomiting. On other occasions, the picture clears up if progressive obstructive jaundice or postural epigastric pain appear, which relieves with flexed or prone trunk. Given the suspicion of a pyloric syndrome due to cancer of the head of the pancreas, computed axial tomography or ultrasound with transcutaneous biopsy of the pancreas will be directly indicated.
There are other rare entities that can give a pyloric syndrome. Thus, the muscular hypertrophy of the adult pylorus is an entity that can be confused with an anthropiloric cancer of onset, since the barium X-ray will show an elongated and rigid pylorus, the fibroscopy does not allow to cross the stenosis, and the biopsies and cytodiagnosis are negative for cancer. Less frequent are other etiologies capable of giving a pyloric syndrome when they invade the antrum: syphilis, tuberculosis, actinomycosis, lymphomas, Crohn's disease, etc. Finally, a pyloric stenosis may remain as a consequence of a surgical intervention of the pylorus, lapyloroplasty.