Gastrointestinal: Acquired double pylorus; long‐term endoscopic observation

Abstract

A 68-year-old man presented at the emergency department of our hospital in September 2006 with symptoms suggestive of upper gastrointestinal hemorrhage. He had taken piroxicam for arthralgias. Retrospective examination of an esophagogastroduodenoscopy (EGD) performed in 2004 to screen for gastric cancer showed no ulcers (Figure 1A). At the time of the patient's arrival at our hospital, physical examination revealed hypovolemia, cold sweating, tachycardia (pulse rate: 110 beats/min), and a systolic blood pressure of 90 mmHg. A complete blood count found a hemoglobin level of 6.7 g/dL and a hematocrit value of 20.5%. The EGD showed a large, deep gastric ulcer with adherent blood clots at the lesser curve of the gastric antrum (Figure 1B). We treated the bleeding with a 1% epinephrine injection and proton pump inhibitors (PPI). One week later, an EGD showed a reduced ulcer base with re-epithelialization. The patient was discharged 10 days later after an uneventful recovery. The patient took PPI and H2-receptor antagonists intermittently, when he had symptoms. An EGD performed 9 months later revealed an accessory pyloric channel on the lesser curve of the antrum, where the ulcer had been observed previously (Figure 1C). The endoscope could be passed from the antrum to the duodenum through either channel. Biopsies of the stomach and septum demonstrated gastritis with no evidence of Helicobacter pylori infection. An EGD performed in January 2011 revealed that the bridge between two channels had disappeared, resulting in a single large opening (Figure 1D). The patient remained asymptomatic during the follow-up period, with no ulcer recurrence. Double pylorus is a relatively rare condition characterized by the presence of a short accessory channel extending from the distal stomach to the duodenal bulb. In most cases, double pylorus is an acquired complication of chronic peptic ulcer disease, but it may also be a congenital abnormality. Most fistulas arise on the lesser curve of the gastric antrum and enter the superior aspect of the duodenal bulb. The reported incidence of this condition in endoscopic series is approximately 0.02%. This abnormality can present with epigastric pain, dyspepsia, and upper gastrointestinal bleeding, or can be found incidentally. Our patient has remained asymptomatic after treatment of the gastric ulcer and discovery of the fistula during routine follow-up endoscopy. Patients respond well to conservative treatment for peptic ulcers. Accessory pylorus channels persist for life in the majority of patients. In some patients, however, such channels close or connect with the true pylorus to form a single channel, as observed in our patient. Surgical intervention is not typically considered a treatment option, although it should be considered in patients with refractory symptoms and other complications. To prevent this complication, early diagnosis and appropriate treatment of the peptic ulcer are necessary. Contributed by