GASTROENT EROLO GY Vol. 56, No.

2
Copyright © 1969 by The Willia ms & Wilkins Co. Printed in U.S.A .

GASTRODUODENAL (PYLORIC) BAND

Endoscopic findings and first reported case

VERNON M. SMITH, M.D., F A

. .C.P., AND KENNETH W. TuTTLE, M.D.
Mercy Hospital, Baltimore, Maryland

The first case in the English literature is reported of a gastroduo-

denal (pyloric) band. The anomaly was correctly diagnosed by fiber-
optic gastroscopy only with the aid of carefully analyzed cinegastro-
scopic motion pictures of the lesion. The literature of pyloroduodenal
anomalies is reviewed. The adjunctive value of cinegastroscopy to
clinical endoscopy in the matter of interpretation of unusual endo-
scopic findings is exemplified by the experience in this case. The ini-
tial endoscopic diagnosis of antral ulcer was incorrect. The correct
diagnosis, of gastroduodenal (pyloric) band, was reached only after
careful analysis of the motion pictures obtamed by cinegastroscopy.
The final endoscopic diagnosis was confirmed at operation.

Except for hypertrophic pyloric stenosis, Case Report

congenital anomalies of the stomach and
pylorus are extremely rare. I The most
common anomalies of this anatomic area
are atresia and prepyloric (antral) dia-
phragm, with varying degrees of patency. 2
Apparently, no previous instance of gas-
troduodenal (pyloric) band has ever been
reported. The authors were unable to find
"any report of this anomaly in the English
literature.
The recent finding, endophotographic
documentation, and operative confirma-
tion of a gastroduodenal (pyloric) band in
a 54-year-old Negro female are described
here as the first such case to be reported,
and because circumstances of the clinical
study of the patient convincingly illus-
trate the adjunctive diagnostic value of
cinegastroscopy to clinical endoscopy.
Received June 20, 1968. Accepted August 23,
1968.
Address requests for reprints to: Dr. Vernon M.
Smith, 301 Saint Paul Place, Baltimore, Maryland
21202.
This work was supported by a grant from The
John A. Hartford Foundation, Inc.
Dr. Tuttle's present address is: Hospital of the
University of Pennsylvania, Philadelphia, Pennsyl-
vania.
331
A 54-year-old Negro female was admitted to
Mercy Hospital in April 1966, following 3 weeks
of vomiting after meals, right upper quadrant
abdominal pain, minor hematemesis, and as-
sociated upper gastrointestinal series radio-
logical changes indicative of an active ulcer of
the gastric antrum. During the episodes of
pain, a mass "like an egg" formed in the epi-
gastrium. The mass was said to shift downward
and to the right at the height of the pain.
The patient had been followed in the Mercy
Hospital outpatient clinic since 1963 for rheu-
matoid arthritis of the small joints. Medication
prescribed during this period included acetyl-
salicylic acid. An esophageal hiatus hernia and
diverticulosis coli were demonstrated by radio-
logical examinations. The patient volunteered
the additional information that during periods
when the arthritis subsided, she would reduce
or discontinue the dosage of acetylsalicylic
acid, and the abdominal pain also would im-
prove.
Physical examination. The patient was a
moderately obese Negro female who did not
appear acutely ill: blood pressure, 150 over
90; pulse, SO, full and regular; respirations,
20 per min; temperature, 37 C. The head,
eyes, ears, nose, and throat were unremark-
able. Moist rales were heard over the left lung
base. The heart was enlarged to the left. The
apical impulse was in the sixth intercostal
332 CASE REPORTS Vol. 56, No.2

space, 2 cm outside the midclavicular line.
The abdomen was obese and soft. There was
mild diastasis recti. The right upper quadrant
of the abdomen was tender to palpation, but
no abnormal mass or organ enlargement was
noted. The rectum contained a small amount
of formed dark brown stool which showed a
positive test for blood (Hematest). There was
fusiform swelling and moderate tenderness of
the proximal interphalangeal joints of the
fingers. The remainder of the physical exami-
nation was within normal limits.
Initial laboratory findings included hemo-
globin, 13.8 g %; hematocrit, 41%; white blood
count, 12,300 with an increased number of
unsegmented polymorphonuclear cells. Uri-
nalysis was normal. Microscopic examination
of the urine sediment disclosed 4 to 6 white
blood cells per high-power field. Total serum
cholesterol was 244 mg per 100 ml. Serological
test for syphilis (Kahn) was doubtfully posi-
tive; Veneral Disease Research Laboratory was
positive. Random blood sugar upon admission
was 120 mg per 100 ml; repeat blood sugar
values were normal. Serum alkaline phospha-
tase was 14.6 Roberts units. Fasting gastric
juice contained 35 mEq per liter of hydro-
chloric acid. The following additional labora-
tory examinations were within normal limits:
serum electrolytes, amylase, albumin, bili-
rubin, thymol turbidity, and blood urea nitro-
gen.
Upper gastrointestinal series radiological
examination revealed a slightly dilated esopha-
gus and a small, sliding esophageal hiatus
hernia. The gastric antrum was narrow. Sev-
eral films showed a niche-like projection of
barium from the greater curvature portion of
the distal antrum (fig. 1). The findings were
interpreted as possibly due to previous ulcer-
ative disease and current active inflammation
and ulceration in the distal antrum. Endo-
scopic examination was requested.
Endoscopic examination. Esophagoscopy

FIG. 1. Upper gastrointestinal series roentgenogram showing barium-filled stomach and duodenum. Arrow
points to pocket of barium initially interpreted as representing an ulcer crater in the distal antrum .
February 1969 CASE REPORTS 333

was normal. Gastroscopy with the ACMI fi-
beroptic gastroscope provided an excellent
view of the distal antrum and pylorus. As the
findings were initially interpreted, there was
a 1.5-cm deep "crater" with a shaded base,
situated on the greater curvature of the distal
antrum just proximal to the pyloric opening.
A strip of Qormal appearing mucosa, approxi-
mately 3 mm wide, lay between the "ulcer"
and the pyloric opening. Antral peristalsis was
active, and :,passed normally through the area.
Intermittent peristalsis of the antrum and clo-
sure of the pylorus were well seen. Motion
pictures we.I;e filmed of the distal antrum and
pyloric opening during numerous consecutive
peristaltic sweeps. Subsequently, following
careful viewing and reviewing of these films
at different projection speeds and with repeated
reversal of action, the true nature of the endo-
scopic findWgs was appreciated. The 3- to 4-
mm strip of normal appearing mucosa initially
described as separating an "ulcer" crater from
the pylorus was recognized actually to be a
discrete band of mucosa situated precisely
at the gastroduodenal junction, and which ex-
tended acro§!, the pylorus to divide it into two
unequal areas (fig. 2). The smaller of these (ap-
proximately one-third of the total opening)
appeared djuk and cavernous, and had been
described as the ulcer crater. The larger area
(remaining two-thirds of the total opening)
had been ,sonsidered to represent the entire
pylorus. In actual fact, then, both openings
together comprised the pylorus which was
transected _{by the narrow band of mucosa-
covered tissue.
Operative findings. At operation on April 15,
1966, the l;>and was found as described . It lay
in an anterior-posterior direction across the
pyloric opening. There was no ulcer. The band
was excised, and a Heineke"Mikulicz pyloro-
plasty was performed. The postoperative
course was unremarkable.
Review of roentgenograms. Following oper-
ation, careful review of the preoperative up-
per gastrointestinal series spot films drew at-
tention to a round radiolucency in the pyloro-
duodenal segment (fig. 3). The radiolucency
was a co~tant finding on several anteropos-
terior projections, and corresponded to the
band found during operation. It was ,concluded
that the radiolucency representea an end-on
view of the band, previously unrecogrlized.
Pathological findings. Microsc<?pic exami-
nation of the excised band (fig. 4) showed it to
consist of muscle bundles sandwiched between
two mucosal layers: gastric mucosa on one side,
duodenal mucosa on the other.
Discussion
No other report of a gastroduodenal
(pyloric) band was found during an exten-
sive search of the English literature. The
nearest, and probably related, anomaly of
this anatomic area is the antral or pyloric
diaphragm .
The first published description of an im-
perforate pyloric diaphragm is that by
Bennett in 1937. 3 Gerber 4 reviewed the
literature in 1964 and found reports of 53
cases. Eight additional cases have since
been reported, bringing the total in the
literature to 61 cases 2 • 5·11 (table 1). Fifteen
of the cases featured pyloroduodenal dis-
continuity. Eight cases were instances of
antral or pyloric atresia and 7 cases were
instances 6f imperforate mucosal dia-
phragm. Terminology has been inconstant,

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FIG. 2. Drawing from motion picture film of the endoscopic view of the pyloric opening in this patient.
The gastroduodenal (pyloric) band divides the pylorus into a smaller opening (initially believed to be a deep
ulcer crater) iand a larger opening (initially believed to be the entire pylorus) . The true nature of things be-
came apparent only after repeated reviews ofthe cine gastroscopic film.
334 CASE REPORTS Vol. 56, No.2

FIG. 3. Preoperative spot film (AP projection) of pyloroduodenal segment. AlTOW points to radiolucency
which corresponded to the band removed during operation. The radiolucency was constant, being recorded
on several additional spot fi,lms also.

FIG. 4. Photomicrograph of the band excised. Shown are the gastric mucosa, duodenal mucosa, and inner
muscular structure (magnification, about 50 X) .
 TABLE 1. Cases reported in order of appearance in literature a

Case Author Year Defect and location

---
I Bennett' 1937 Imperforate pyloric diaphragm
2 Touroff and Sussman' 1939 Imperforate pyloric and antral web
3 Metz' 1941 Double imperforate pyloric and antral web
4 Berman' 1942 _ Antral diaphragm with I-mm ostia
5 Holladay' 1946 Atresia of pylorus
6 Swartz 5 1946 Antral diaphragm with l-cm ostia
7 Albot and Magnier' 1946 Pyloric diaphragm
8 Burnett' 1947 Atresia-of pylorus
9 Sames' 1949 Antral web with 3"mm ostia
10 Lemak' 1951 Imperforate antral diaphragm
11 Benson' 1951 Imperforate pyloric diaphragm
12 Fell' 1951 Imperforate pyloric diaphragm
13 Gross' 1953 Antral diaphragm with 3-mm ostia
14 Rota' 1953 Pyloric diaphragm with 4-mm ostia
15 Passalacqua' 1955 Pyloric diaphragm with 6-mm ostia
16 Swartz and Shepard 5 1956 Antral diaphragm with l-cm ostia
17 DeSpirito' 1957 Pyloric diaphragm with 5-mm ostia
18 Cf)ffey' 1957 Pyloric diaphragm
19 Briety' 1957 Antral diaphragm
20 Brown' 1959 Antral atresia
21 Brown' 1959 Antral atresia (2 different cases 7 and 10 days old)
22 Lauste' 1959 Antral atresia
23 Rhind' 1959 Pyloric diaphragm
24 Rhind' 1959 Pyloric diaphragm
25 Rhind' 1959 Pyloric diaphragm with 3-mm ostia, age 59
26 Rhind' 1959 Pyloric diaphragm with 3-mm ostia, age 70
27 Rhind' 1959 Pyloric diaphragm with 2-mm ostia
28 Rhind' 1959 Pyloric diaphragm with 4-mm ostia
29 Rhind 4 1959 Pyloric diaphragm with 2-mm ostia
30 Rowling' 1959 Pyloric diaphragm
31 Rowling' 1959 Antral diaphragm
32 Chamberlain' 1959 Pyloric diaphragm with I-mm ostia
33 Chamberlain' 1959 Pyloric diaphragm with 4-mm ostia
34 Salzberg 4 1960 Pyloric diaphragm
35 Davis' 1961 Pyloric diaphragm
36 Spencer4 1961 Pyloric diaphragm
37 Young' 1961 Pyloric diaphragm with I-mmostia
38 W urtenberger 4 1961 Pyloric diaphragm with no ostia
39 Wurtenberger 4 1961 Pyloric diaphragm
40 Kornfield' 1962 Pyloric atresia
41 Kornfield' 1962 Pyloric atresia
42 Popescourluieni' 1962 Pyloric diaphragm
43 Kenny' 1963 Pyloric diaphragm with 2-mm ostia
44 Kenny' 1963 Pyloric diaphragm
45 Kenny' 1963 Pyloric diaphragm with I-mm ostia
46 Kenny' 1963 Pyloric diaphra.gm with 2-mm ostia
47 Liechti' 1963 Antral diaphragm with 3-mm ostia
48 Becker' 1963 Pyloric atresia
49 Bergeron 4 1963 Pyloric diaphragm with 2-mm ostia
50 Munro' 1963 Antral diaphragm with 3-mm ostia
51 Dineen' 1963 Pyloric diaphragm
52 Stahl' 1963 Pyloric diaphragm
53 Browning 4 1964 Antral diaphragm
54 Gerber 4 1964 Antral diaphragm
55 Pulsifer et al. 6 1965 Pyloric diaphragm
56 Conway' 1965 Pyloric diaphragm
57 Parrish!O 1966 Antral membrane
58 Sloop7 1967 Pyloric diaphragm
59 Robinson" 1967 Pyloric diaphragm
60 Cremin' 1967 Pyloric diaphragm
61 Banks et al. 11 1967 Antral diaphragm

a Reports of cases 1 to 5, 7 to 15, and 17 to 54 were cited by Gerber.'

335
336 CASE REPORTS
with some authors referring to atresia and
others, to imperforate diaphragm. Any
difference is probably ' relatable to the de-
gree of separation between stomach and '
duodenum.
Forty-six cases were instl;lllces of antral
or pyloric mucosal diaphragm. It was typi-
cal of these cases that, despite very small
ostia (1 to 10 mm) proved surgically, the '
patients curiously presented symptomati-
cally either early in childhood (before the
age of 5 weeks) or not until adulthood. The
youngest adult was 32 years old. The four
exceptions to this pattern were children,
all of whom had ' actually been sympto-
matic since birth. Definitive surgery was
often delayed because the condition was
not recognized for some time.
No certain explanation is available for
the separated peaks of clinical incidence:
in early childhood, and after attainment
of adulthood. The question maybe raised
whether or not the earlier occurrences of
obstruction are due to congenital lesions,
and the later lesions are acquired. Most '
authors believe it .is a congenital condi-
tion 12 ; others 13 believe it may also occur
as a sequela of localized scar formation.
The capability of liquid chyme to pass
through a very small opening during
peristalsis has been . well demonstrated by
the cases of diminutive ostia. Later, after
a latent period, changes associated with
gastritis or ulceration associated with
spasm may aggravate the obstructive ten-
dencies, and produce the clinical syndrome
which leads to discovery of the lesion.
Furthermore, the patient's dentition may
influence the clinical appearance of symp-
tomatology as it affects mastication and
particle size of swallowed food. Certainly
the size of the ostia does not appear to be
a major factor in production of symptoms
if the lesion is congenital. The smallest
openings reported (1 mm) were found in
3 patients aged 53, 62, and 65, respec-
tively.
The patient reported here is unique in
several respects. The band in this patient
Vol. 56, No.2
was composed of the usual gastric and du-
odenal mucosal surfaces associated with
antral diaphragms, but also, uniquely con-
tained a central mass of true muscle tis-
sue. This band, therefore, had the ana-
tomic prerequisities for contraction and
shortening, a situation of considerable po-
tential significance when related to the
clinical picture of intermittent pyloric ob-
struction. A further possibility, that in-
gestion of salicylate drugs, known to cause
this patient to experience abdominal dis-
tress, may have induced inflammation
and/or scarring, is speculative.
REFERENCES
1. Webb, C. H., and O. H. Wangensteen. 1931.
Congenital intestinal atresia. Amer. J. Dis.
Child. 41: 262-284.
2. Conway, N. 1965. Pyloric antral mucosal dia-
phragm. Brit. Med. J. 1: 970-971.
3. Bennett, R. J., Jr. 1937. Atresia of the pylorus.
Amer. J. Dig. Dis. Nutr. 4: 44.
4. Gerber, B. C. 1965. Prepyloric diaphragm: an
unusual abnormality. Arch. Surg . (Chicago)
90: 472-480.
5. Swartz, W. T., and R. D. Shepard. 1956. Con-
genital mucosal diaphragm of the pyloric an-
trum. J. Kentucky Med. Assn. 54: 149-151.
6. Pulsifer, L., F. L. Jedd, and T. F. Van Zandt.
1965. Pyloric obstruction by a mucosal dia-
phragm. Amer. J. Gastroent. 43: 30-34.
7. Sloop, R. D., and A. C. W. Montague. 1967. Gas-
tric outlet obstruction due to congenital py-
loric mucosal membrane. Ann. Surg. 165:
598-604.
8. Robinson, K. P. 1967. Pyloric stenosis due to a
mucosal diaphragm. Brit. J. Surg. 54: 397-
399.
9. Cremin, B. J. 1967. Neonatal pre-pyloric mem-
brane. S. Afr. Med. J. 41: 1076-1079.
10. Parrish, R. A., Jr., H. S. Sherman, and W. H.
Moretz. 1966. Congenital antral membrane.
Surgery 59: 681-684.
11. Banks, P. A., J . D. Waye, A. M. Waitman, and
A. Cornell, 1967. Mucosal diaphragm of the
gastric antrum . Gastroenterology 52: 1003-
1008.
12. Rowling, J. T . 1959. The prepyloric septum:
rare anomaly. Brit. J. Surg. 47: 162-166.
13. Rhind, J. A. 1959. Mucosal stenosis of the
pylorus. Brit. J. Surg. 46: 534- 540.