In this position the growth may either form a ring round the bowel, just below the pylorus, or produce a deep ulcer with overhanging edges, the base of which is adherent to the liver or pancreas. In both cases the lumen of the intestine is considerably diminished, though never entirely obstructed. The complaint is chiefly encountered in men of middle age, and sometimes follows simple ulceration.
The initial symptoms are somewhat indefinite, and principally consist of discomfort and flatulence after meals, acidity, loss of appetite, and general debility. There is also slight but progressive loss of flesh, with marked pallor of the. mucous membranes. After a month or two pyrosis makes its appearance, and is followed within a short time by vomiting. At first the emesis may occur only about once a week, and is followed by an amelioration of the other symptoms ; but it gradually becomes more and more frequent, until finally it takes place once or twice every twenty-four hours. The vomit consists of an acid sour-smelling liquid, mixed with masses of undigested food. Free hydrochloric acid is usually absent, but lactic acid may be present in excess. It is generally stated that the ejecta are free from bile, but as a matter of fact a severe attack of retching is not infrequently accompanied by the rejection of a green bilious fluid which has regurgitated through the incomplete stricture. At this period severe pain may be experienced in the epigastrium or right hypochondrium shortly after meals, and is almost always an indication that the growth has undergone superficial ulceration. Haematemesis is less frequent than in cancer of the stomach, but traces of altered blood may sometimes be observed in the stools, and occasionally there is severe melaena. In the early stages of the complaint the bowels are confined, but subsequently diarrhoea may supervene and prove difficult to control. Bile is usually present in the stools, and, according to Charon and Ledegank, colloid material may often be recognised in the evacuations when the disease has undergone that form of degeneration.
On examination the stomach is found to be greatly dilated, and its contractions are often visible through the abdominal wall. In about 60 per cent, of the cases in which the disease is situated close to the pylorus a tumour may be detected upon palpation, and is sometimes large enough to be evident upon inspection. It is usually oval or globular in shape, smooth on the surface, dull on percussion, painful, and slightly movable; but if it is adherent to the liver or pancreas its outlines are less definite, and the presence of the colon in front of it may endow it with a resonant note.
The subsequent course of the disease is similar to that of pyloric cancer. Ascites may occur from carcinoma of the peritoneum or pressure upon the portal vein, while jaundice may result from secondary growths in the liver or from an extension to the biliary papilla. Perforation into the general cavity of the peritoneum is a rare event, but a slight leakage not infrequently gives rise to a localised abscess, which burrows upwards to the diaphragm or points near the umbilicus.