Alimentary Sphincters and their Disorders

241 Pages·1981·25.626 MB·English

by  Paul A. Thomas, Charles V. Mann (eds.)

ALIMENTARY SPHINCTERS
AND THEIR DISORDERS
ALIMENTARY
SPHINCTERS
AND THEIR
DISORDERS
Edited by
Paul A. Thomas
Senior Lecturer and Consultant Surgeon, The London Hospital,
London, El IBB
and
Charles V. Mann
Consultant Surgeon, The London and St Mark's Hospitals, London
M
© Paul A. Thomas and Charles V. Mann 1981
Softcover reprint ofthe hardcover 1st edition 1981
All rights reserved. No part of this publication may be reproduced or
transmitted, in any form or by any means, without permission.
First published 1981 by
Scientific and Medical Division
MACMILLAN PUBLISHERS LTD
London and Basingstoke
Companies and representatives throughout the world
Filmset by Reproduction Drawings Ltd., Sutton, Surrey
ISBN 978-1-349-03942-5 ISBN 978-1-349-03940-1 (eBook)
DOI 10.1007/978-1-349-03940-1
Contents
The Contributors vii
Preface ix
1. Anatomy of the sphincters of the alimentary canal 1
Introduction 1
Pharynx 2
Gastro-oesophageal (cardiac) sphincter 8
Pylorus 9
Sphincter of Oddi 10
Ileocaecal valve 12
Anal sphincters 14
2. Pharmacology of human gastrointestinal sphincters 27
Introduction 27
Relative advantages of in vivo and in vitro techniques for
studying sphincters 28
The upper oesophageal (cricopharyngeal) sphincter 32
The lower oesophageal sphincter 33
The pyloric ring 45
Choledochoduodenal and pancreatic duct sphincters 47
The ileocaecal sphincter 51
The rectosigmoid junction 53
The internal and external anal sphincters 53
General conclusions 56
3. The cricopharyngeal sphincter 67
Anatomy 67
Physiology 68
Medical and surgical therapeutic implications in disease 70
4. The gastro-oesophageal sphincter 75
v
vi CONTENTS
Introduction 75
Anatomy 75
Physiology 77
Methods of investigation in man 82
Disorders of sphincter function 88
Future advances 93
5. The pylorus 101
Anatomy 101
Physiology 105
Investigative techniques in man 116
Medical and surgical therapeutic implications in disease 121
Possible future advances 128
6. The biliary sphincter 135
Introduction 135
Anatomy 136
Physiology 140
Inflammatory lesions of the sphincter of Oddi 148
Therapeutic considerations in sphincteric disorders 152
7. The pancreatic sphincter 173
Anatomy 173
Physiology 180
Medical and surgical therapeutic implications in health and
disease 186
Investigative techniques in man and possible future
advances 188
8. The ileocaecal junction 193
Anatomy 193
Physiology 194
Techniques of investigation 195
Therapeutic implications 197
Conclusion 198
9. The rectosigmoid junction zone: another sphincter? 201
Evidence for a rectosigmoid sphincter mechanism 201
Experimental observations 205
Discussion 210
10. The anal sphincters 213
Structure 213
Function 218
Pathophysiology 221
Summary 224
11. Editorial summation 227
Index 233
The Contributors
W. N. W. Baker, MS, FRCS H. L. Duthie, MD, ChM, FRCS
Dept of Surgery Welsh National School of
Ashford Hospital Medicine
Middlesex Cardiff, South Glamorgan
T. W. Balfour, MB, ChB, FRCS
C. E. Gabriel, MB, ChB, DLO
Dept of Surgery
Dept of Otorhinolaryngology
Nottingham Medical School
ENT Hospital
Greenock, Scotland
A. Bennett, BPh, DSc, PhD
Dept of Surgery
King's College Hospital Medical A. G. Johnson, MCh, FRCS
School University Surgical Unit
London, SE5 Hallamshire Hospital
Sheffield, South Yorkshire
A. D'Mello, MSc, PhD
Dept of Pharmacology
F. B. Keane, MB, FRCS
The London Hospital Medical
Dept of Surgery
College
St James Hospital
London, El 2AD
Dublin, Irish Republic
E. P. DiMagno, MD
Gastroenterology Unit P. McKelvie, MD, ChM, FRCS
Mayo Clinic Dept of Otorhinolaryngology
Rochester, Minnesota 55901, The London Hospital
USA London, El lBB
vii
viii THE CONTRIBUTORS
C. V. Mann, MCh, FRCS P. A. Thomas, BSc, MS, FRCS
Dept of Surgery Dept of Surgery
The London Hospital The London Hospital
London, El lBB London, El lBB
A. G. L. Peel, MA, MChir, H. H. Thompson, BSc, FRCS
FRCS Dept of Surgery
North Tees General Hospital The London Hospital
Stockton-on-Tees London, El lBB
Cleveland
D. R. E. Reeve, PhD, MD,
FRCS
Dept of Anatomy
The London Hospital Medical
College
London, El 2AD
Preface
What is a sphincter? It used to be thought that the function of the
specialised areas defined as 'sphincters' was to delay the onward passage of
the fluids and solids from the organs which 'emptied' through them. It is
now realised that this concept was too facile, and that these zones act in a
very complex regulatory fashion and that they are able to change their
functions to suit the requirements of the whole gastrointestinal tract. Nor is
the organisation of each sphincter an exact replica of the rest: some are
'closed' and some are 'open'; some have a well-defined anatomical
structure, others are not defined at all; some act as 'brakes' but others can
possess an acceleratory characteristic.
With the increasing power of modern pharmaceutical ingredients, many
of which (e.g. ganglion-blocking agents and prostaglandins) act directly on
the smooth muscle of the alimentary canal, as well as the much increased
safety and numbers of major surgical interventions, we considered it
appropriate to draw together the current knowledge and ideas concerning
the sphincters of the gastrointestinal tract. As these sphincteric regions are
perhaps the most widely investigated areas of alimentary motor function,
they provide well-defined examples of the correlation between
gastrointestinal motor dysfunction and recognised clinical disorders. It is
hoped that showing how they perform their functions will stimulate further
research as well as increasing the respect that they deserve from all those
physicians and surgeons who interfere with them.
The book would not have been possible without the full co-operation of
the contributors. Each has brought to his work a high level of expertise,
thoughtfulness and clarity of expression. It is especially relevant that most
of the contributors are actively involved in the practice of clinical
gastroenterology, which has enabled them to provide a relevant correlation
between basic scientific data and the clinical disorders of sphincteric
ix
X PREFACE
function. We are extremely grateful to them all for their contributions.
On a sad note, we have to report the untimely death of Mr David Reeve,
whose surgically orientated chapter on the anatomy of alimentary
sphincters provides the introduction to this book.
We are indebted toMs Linda Bray for helping with the editing and typing
of the manuscripts, together with Ms Lynda Randall, Diane Tolfree and
Jenny Bignold.
Finally, our publishers have been helpful throughout, and we are grateful
to Mr R. M. Powell of Macmillan Publishers for his succinct advice on the
practicalities of producing a book such as this one.
London, 1981 PAT
CVM