Demonstration of a physiologic sphincter at duodeno-jejunal junction

[Duodenal motility in norm and in some diseases. Hypothesis]

AIM

to investigate the duodenal motility on the basis of radiological studies.

PATIENTS AND METHODS

We tested our hypothesis that sphincters of Kapandji and Ochsner are contracted in response to stimulation of duodenum by hydrochloric acid. These sphincters are not found in standard X-ray studies because barium does not contain hydrochloric acid when it coming from the stomach into the duodenum. The retrospective analysis of radiological studies of the upper digestive tract of 116 patients aged 55 to 92 years was done. The first group consisted of 83 patients in whom the study was conducted using conventional barium suspension. The second group consisted of 8 patients who received 200 ml of barium with the addition of 3 grams of vitamin C. The third group was comprised of 25 patients with primary duodenal diverticula. The fourth group included radiographs from 35 articles devoted to the superior mesenteric artery syndrome (SMAS). We measured the width of the duodenum and the length of the sphincters on these radiographs.

RESULTS AND CONCLUSION

We found an important role of the sphincters (bulbo-duodenal, Kapandji, Ochsner) in the duodenal physiology. On this basis, we proposed the hypothesis defining basic patterns of the duodenal motor function. Proposed hypothesis allows us to understand how the duodenum performs important functions and provides new avenues for understanding the pathogenesis of acquired diseases of the upper gastrointestinal tract. The different forms dyskinesia of these sphincters play an important role in the pathogenesis of the SMAS, primary duodenal diverticula and sphincter Oddi dyskinesia.

Duodeno-jejunal junction: a histoanatomical study with the concept of the existence of an "anatomical" sphincter

BACKGROUND

Duodenojejunal junction (DJJ) pressure decreased on duodenal contraction and increased on jejunal contraction. These findings postulated potential existence of anatomical sphincter at DJJ.

METHODS

DJJ was studied by direct dissection in 34 cadavers and histologically in 24. Transverse and longitudinal sections across DJJ were cut and stained.

RESULTS

DJJ was narrower than duodenum or jejunum and had one or two grooves occupied by arterial branch derived from superior mesenteric artery and we call it "duodenojejunal junction artery". DJJ was thicker on palpation than duodenum or jejunum. Its mucous membrane was crowded into "DJJ rosette". DJJ length varied in adults from 0.75 to 0.9 cm. Microscopically, circular muscle layer was thickened at DJJ.

CONCLUSION

The thickened circular muscle, mucosal rosette and narrowing at DJJ point to possible existence of anatomical sphincter at DJJ. Together with presence of high-pressure zone at DJJ, these findings would support such postulation.

Duodeno-jejunal junction dyssynergia: Description of a novel syndrome

AIM: To investigate the hypothesis that duodeno-jejunal dyssynergia existed at the duodeno-jejunal junction.

METHODS: Of 112 patients who complained of epigastric distension and discomfort after meals, we encountered nine patients in whom the duodeno-jejunal junction did not open on duodenal contraction. Seven healthy volunteers were included in the study. A condom which was inserted into the 1^st duodenum was filled up to 10 mL with saline in increments of 2 mL and pressure response to duodenal distension was recorded from the duodenum, duodeno-jejunal junction and the jejunum.

RESULTS: In healthy volunteers, duodenal distension with 2 and 4 mL did not produce pressure changes, while 6 and up to 10 mL distension effected significant duodenal pressure increase, duodeno-jejunal junction pressure decrease but no jejunal pressure change. In patients, resting pressure and duodeno-jejunal junction and jejunal pressure response to 2 and 4 mL duodenal distension were similar to those of healthy volunteers. Six and up to 10 mL 1^st duodenal distension produced significant duodenal and duodeno-jejunal junction pressure increase and no jejunal pressure change.

CONCLUSION: Duodeno-jejunal junction failed to open on duodenal contraction, a condition we call ‘duodeno-jejunal junction dyssynergia syndrome’ which probably leads to stagnation of chyme in the duodenum and explains patients' manifestations.