Double Pylorus: An Optical Illusion or Reality?

Abstract

Question: A 30-year-old woman underwent an upper gastrointestinal endoscopy for dyspepsia for 2 months not responding to proton pump inhibitors. The esophagus and stomach was normal except for the appearance of 2 pyloric openings (Figure A). She had no history of surgery. Further examination showed normal duodenum. Patient underwent an endoscopic ultrasound to confirm the diagnosis (Figure B, C; Video Clip 1). What is the diagnosis? If the second opening is virtual, which one is that and what does it correspond with? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The apparent second pyloric opening was a deep indentation in distal antrum close to the pylorus (Figure D). Endoscopic ultrasonography over this area showed a relatively hypoechoic lesion (measuring about 2.3 × 1.2 cm, indistinct margins) with heteroechoic areas and rudimentary ducts arising from the submucosal layer suggestive of ectopic pancreatic tissue (Figure E; Video Clip 1). Ectopic pancreas is pancreatic tissue that has neither anatomic nor vascular continuity with the normally located pancreas. Autopsy series show a prevalence of 0.6%–13.7%.1Armstrong C.P. King P.M. Dixon J.M. et al.The clinical significance of heterotopic pancreas in the gastrointestinal tract.Br J Surg. 1981; 68: 384-387Crossref PubMed Scopus (186) Google Scholar In 90% of cases, ectopic pancreatic tissue is found in the stomach. It is usually detected as an incidental finding, as in our case. Endoscopically, ectopic pancreas appears as a submucosal nodule with a central umbilication or depression, which represents a draining pancreatic duct. Deep indentation resembling a second pylorus is an uncommon presentation. On endoscopic ultrasonography, it is usually located in the submucosa, but may extend to the muscularis propria and subserosa. Ectopic pancreas appears hypoechoic relative to the surrounding submucosa, with a heterogeneous echotexture. The margins are usually indistinct because of the lobular structure of acinar tissue.2Matsushita M. Hajiro K. Okazaki K. et al.Gastric aberrant pancreas: EUS analysis in comparison with the histology.Gastrointest Endosc. 1999; 49: 493-497Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar The appearance on endoscopic ultrasonography is characteristic and usually requires no treatment. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJjMmYzZWI3OGJkM2VlZDI5MDhiYTQ2YTdiMmZjNGNlNyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc3MTc5NjQ2fQ.QGLmDaiX4YTHLIJD-wM-bCJbUMnt17cLtUKiUfzR-ElIAi_F-S-uAkQDPdofSJvWBmyxyAY_2CnoXnFGnxuCMu6lO4CMHoxfUWzD3v5EKrsIQ7iATt1EurQbi0f_dQcM4l5hdhpAPIkxuunDuiUk1Gn_LUOjI85FZs6lpRfmD2jqarfaE6R2ZgFrxFmpGC-6vtkANFZMu78tCBMoN-pfUbHmVbJSmlCBKhgf1PjB1u5ZC2NOa51DCQKiWSD2hUTQpHgotv4pxjf4j6aoVs1Ermw6V2-Vbt3s4nxVdM2ahKU9q1XUCAaZQRtN0R8n8eG1p_8cSyGNTmPnPpZxcArhUA Download .mp4 (6.63 MB) Help with .mp4 files Video Clip 1