Acquired Double Pylorus (ADP): A Rare Complication of Peptic Ulcer Disease

Abstract

Introduction: Double pylorus (DP) is a rare condition that can be either congenital or acquired. ADP occurs when a peptic ulcer erodes and creates a fistula between the duodenal bulb and the distal stomach. While extremely rare and usually asymptomatic these may occasionally present with abdominal pain or UGIB. Management requires focus on underlying predisposing factors such as PUD or H.pylori. Case: 84 year-old-male with history of CKD, CHF, iron deficiency anemia presented to the ED with complaints of black tarry loose stools and fatigue for a few weeks. He denied any nausea, vomiting or abdominal pain. He also reported constipation and a 20 pound weight loss over the last several months. He also reported a history of gastric ulcer several years ago and colon polyps with last surveillance colonoscopy about 10 years ago. His vital signs were stable and the lab work revealed a hemoglobin and hematocrit of 7.5 g /dl/and 23.2 %. Digital rectal exam revealed an irregular mass in the posterior aspect of the rectum with red blood mixed with black stool. EGD showed a normal stomach along with a DP. Both the channels could be traversed with ease. Two non-bleeding cratered ulcers were seen in the duodenal bulb. Colonoscopy showed a polypoid non-obstructing mass was found in the distal rectum along with black colored blood in the entire colon. Histopathology showed chronic inflammation of gastric mucosa, but negative for H. pylori. Rectal mass, biopsy demonstrated a moderately differentiated adenocarcinoma with extensive necrosis. Patient continued to be on PPI twice daily with no subsequent episodes of melena and was also started on chemoradition for his rectal cancer. Discussion: DP is a rare entity with aprevalence of 0.001%-0.4%. While the congenital variant may be secondary to a gastrointestinal duplication abnormality, ADP is usually a complication of a gastric or duodenal ulcer leading to wall perforation and creation of a fistula. In our patient the etiology was likely acquired due to a prior history of PUD and also the presence of ulcers and inflammation on EGD and biopsy. Systemic diseases like DM that may affect mucosal microcirculation and medications such as NSAIDS and steroids that may impair mucosal healing have been implicated. Medical management usually encompasses acid suppression and testing and treating for H. Pylori, whereas complicated cases may need surgical intervention.2657_A Figure 1. Esophagogastroduodenoscopy shows double pylorus with two patent channels2657_B Figure 2. EGD also showed presence of duodenal bulb ulcer with pigmentation.