Gastric mucosal diaphragm.

Abstract

AGASTRIC mucosal diaphragm is a thin membranous septum which partially occludes the outlet of the stomach and usually causes some degree of gastric obstruction. Since this unusual anomaly is surgically correctable, its preoperative recognition is important. Four cases are presented to emphasize its clinical, pathologic, and roentgen features. CASE I: This 78-year-old Negro gave a history of three years of intermittent epigastric pain and fullness aggravated by eating and relieved by vomiting, which occurred a half hour or more after meals. The vomitus consisted of undigested food. The symptoms gradually worsened, and he lost about 5 pounds. Three weeks before admission to Cincinnati General Hospital, he went on a liquid diet, which relieved the vomiting. Physical examination revealed a thin, edentulous man, normal except for mild cardiomegaly and hyperactive bowel sounds. Routine laboratory studies were normal. An upper gastrointestinal series showed considerable gastric retention, and prolonged gastric suction was required to permit a satisfactory roentgen study. A persistent band-like constriction was seen about 2 ern proximal to the pylorus (Fig. 1). Although barium flowed freely through the area, the stomach was dilated. Films from a study three years earlier showed similar findings. At operation, the distal antrum was partially obstructed by a soft, pliable mucosal diaphragm with a central opening 3 to 4 rnrn in diameter. The diaphragm was incised but not removed, and a Mikulicz pyloroplasty was performed. Roentgen study a year later was normal. CASE II: For two years this 74-year-old Caucasion male complained of nausea and vomiting of undigested food three to four hours after meals. Six months before admission to Cincinnati General Hospital, the symptoms worsened and he lost his appetite, with a consequent weight loss of 30 pounds. Physical examination disclosed a thin, dehydrated, elderly man with epigastric fullness. A stool specimen showed a 4+ guaiac reaction. Routine laboratory studies were normal. Upper gastrointestinal examination showed a persistent, smooth, linear, transverse, prepyloric defect partially obstructing the gastric outlet (Fig. 2). At times, the defect appeared to prolapse into the bulb. At laparotomy, the stomach looked normal except for the thickening of its walls and some scarring over its external surface secondary to a prior cholecystectomy. Upon opening of the stomach, a mucosal diaphragm located 1 to 1.5 cm proximal to the pyloric ring was found (Fig. 3). It showed a central aperture approximately 3mm in diameter. The diaphragm was excised and pyloroplasty performed. The excised tissue revealed a layer of normal submucosa and hypertrophied muscularis mucosae sandwiched between two layers of gastric mucosa. There was moderate nonspecific inflammation but no fibrosis. The patient became asymptomatic postoperatively.