Hour-glass stricture of the stomach and iron deficiency.

THE object of this note is to put forward the hypothesis that hour-glass stricture of the stomach occurs in persons with a chronic simple gastric ulcer of the lesser curvature, because these persons also have chronic iron deficiency, and that the stricture would not occur without the co-existence of the iron deficiency. Seven cases are described. An association with Plummer-Vinson stricture of the cervical oesophagus and with duodenal stricture is recorded. The X-ray appearances are reproduced. The haemoglobin and serum iron estimations are recorded. Gastroscopy was done in one case. One case was operated on. Important reviews of hour-glass stomach include those of Moynihan (1904) Hurst and Stewart (1929) and Bockus (1943). Hour-glass deformity of the stomach occurs almost exclusively in women. It is due to a stricture of the body of the stomach, by which the greater curvature is deeply drawn in medially towards a point on the lesser curvature. At that point there is, or has been, a chronic simple ulcer. It is probable that the adhesion of the gastric ulcer to adjacent structures provides a fixed point to which the contracting scar draws in. The stricture does not occur unless there has been at some time a chronic simple ulcer. It divides the stomach into an upper and a lower loculus, neither of which is contracted or sclerosed. The passage between the two loculi may get very small, but total obstruction, if it ever occurs, must be rare. Hour-glass stomach does not correctly describe the appearance, because the stomach is not waisted symmetrically at the mid-point of its lumen, but rather eccentrically at the lesser curvature. The appearance is reminiscent of that of the Plummer-Vinson stricture in the cervical oesophagus as seen in lateral X-ray views. Normally a chronic simple gastric ulcer heals with a little local scar. The scar that causes the hour-glass narrowing is an abnormal scar, and is submucosal. The gastric ulcer is not often very active, but it rarely heals, and some ulcer pain is a regular feature. Difficulty in eating is common. This is partly because of the small size of the upper loculus which produces "small stomach" symptoms, and partly because of obstructive feelings. These the patient may interpret as difficulty in swallowing. Impaired nutrition and impaired strength follow. PlummerVinson stricture may co-exist, to add cervical oesophageal dysphagia to the difficulty in eating, and to add a particular difficulty in eating meat. As a rule the gastric mucosa is hypotrophic or atrophic. Gastric mucosal secretory activity is low. Malignant change at the site of the scar does not seem to happen. This is an important difference from Plummer-Vinson stricture. The incidence of hour-glass stomach has fallen of recent years. This may be due to a fall in the incidence of gastric ulcer, to improved treatment of iron deficiency, to better medical treatment of gastric ulcer, or to earlier surgical