C H O L E L I T H I A S I S S I M U L A T I N G P Y L O R I C N E O P L A S M 105

CHOLELITHIASIS SIMULATING PYLORIC NEOPLASM

BY DONALD YOUNG CONSULTANT SURGEON, WARRINGTON INFIRMARY

CASE REPORT THE patient, R. L., a man aged 72 years, was seen in February 1954, giving a history of having had discomfort in his epigastrium for four weeks. This came on as an acute attack of epigastric pain while he was at work. He was treated at home under his own doctor’s care for

When the gall-bladder was separated from the anterior wall of the duodenum a fountain of small gall-stones sprayed up from the stomach opening. This phenomenon was explained by the fact that the mucous membrane had been separated from the wall for 2 in. and this space had been packed with small faceted gall-stones.

FIG. 138.-Radiograph showing constant filling defect at pylorus.

three weeks and seemed to be improving. He then had a rigor and vomited and complained of further pain in his epigastrium.

ON ExAMINATIoN.-There was a smooth, large, non- tender mass on the right side of the epigastrium, which was suspected of being a carcinoma of the stomach or a large secondary in the liver.

A barium series was arranged and reported on as follows : ‘‘ Screen examination of the chest revealed that the aorta was a little dilated. The lung fields were clear. Barium flowed normally down the mophagus. No irregularity was demonstrated at the lower end of the oesophagus. The liver is enlarged. There is a persistent deformity at the pylorus ; I found it extremely difficult to fill. There is a defect shown in all the films. This is not due to spasm and the appearance suggests that there is infiltration of the pyloric antrum, probably neoplastic.” (pg. 138.)

The patient s short history of epigastric pain and the marked loss of weight seemed to confirm the X-ray diagnosis. His general condition was poor, but it was thought that partial gastrectomy under local anaesthesia might be possible as a palliative measure.

AT OPERATION.- On Feb. 26, under local anaesthesia, a midline incision disclosed a mass of adhesions under the liver around the gall-bladder and duodenum. Dissec- tion revealed an inflammatory gall-bladder adherent to the anterior duodenal or pyloric wall, with penetration of the muscular wall but not of the mucous membrane WE. 139).

6.aww*5. FIG. 13g.-Diagram of condition found at operation.

Cholecystectomy was performed. The gap in the muscle wall at the pylorus was closed with interrupted catgut.

He made an uneventful recovery.