13207              CHRONIC PYLORIC ULCER WITH PYLORIC STENOSIS

The patient was a man aged 60 who had suffered intermittently from dyspepsia for 25 years.  Ten years after the onset he experienced difficulty in eating and swallowing and barium meal showed an oesophageal diverticulum.  For two years before his last admission he had been unable to eat a full meal and began vomiting with increased frequency.  He lost 19 kg in weight and developed constant epigastric pain maximal 30 minutes after eating, often severe at about 2 am and waking him from sleep, and usually relieved by alkali and vomiting.  For the last 6 weeks vomiting was increasingly frequent.  On admission the BP was 140/175.  There was vague epigastric tenderness and central abdominal distension with visible peristaltic waves travelling from the left hypochondrium to the right iliac fossa and back.  The haemoglobin was 9.1 gms, reticulocytes 0.85.  The serum Na was 130 m.Eq/l, K 3.8, Cl 81, BUN 13 mg.%.  Barium meal showed the diverticulum in the lower oesophagus and no barium had left the stomach after 24 hours.  Gastric lavage yielded 3 litres of foul brown fluid and a further 1.5 litres next morning.  On the 6th evening the temperature was 100.5ºF and he had a cough, but in spite of this the operation of gastroenterostomy with vagotomy was performed next morning.