2788 Double Pylorus in a Patient With Alcoholic Cirrhosis and Intractable Vomiting

Abstract

INTRODUCTION: Gastroduodenal fistula (GDF) or double pylorus is a rare, often asymptomatic, condition with a prevalence of approximately 0.02-0.08%. The majority of previously reported cases have been in Asian countries and it has been found to be more prevalent in males than females. Although Helicobacter pylori and NSAID use has been associated with the formation of gastroduodenal fistulae, the actual mechanism of the condition is unknown. CASE DESCRIPTION/METHODS: We present the case of a 65-year old female with alcoholic cirrhosis and a long history of intractable vomiting due to unknown etiology. She was found to have a pre-pyloric gastric antral ulcer during an emergent endoscopy for an episode of hematemesis seven years ago. Follow up endoscopies over a course of three years found the antral ulcer to be healing. Seven years from the discovery of the initial lesion, a gastroduodenal fistula was found. The pre-pyloric antral ulcer in the process of healing fistulized into the duodenal bulb creating the appearance of a double pylorus. DISCUSSION: Gastroduodenal fistula or double pylorus can be acquired or congenital. Acquired GDF is a very rare complication of peptic ulcer disease. They can be a result of healing due to bridging fibrosis within the pylorus or, as in this case, fistulization from the gastric antral ulcer. Most GDF are found incidentally during endoscopy that was done for another reason. This case report follows the serial endoscopic examination of a cirrhotic patient with a pre-pyloric antral ulcer that developed into GDF. We propose that the GDF was caused by fistulization of a pre-pyloric antral ulcer with no other predisposing factors and gastrointestinal fistulization processes.