Is Cirrhosis a Risk Factor for Acquired Double Pylorus?

Abstract

Double pylorus (DP) refers to the presence of two separate openings from the stomach into the duodenum. It can be acquired or congenital. We present an interesting case of DP in a patient with cirrhosis which was incidentally found on esophagogastroduodenoscopy (EGD). A 54-year-old male with a past history of obesity and alcohol related cirrhosis presented to our outpatient liver clinic to establish care. The patient was diagnosed with cirrhosis few months ago. He reported a history of significant alcohol use for more than 20 years. Patient also had a history of tobacco use for 30 years but quit 2 years ago. His cirrhosis was decompensated as manifested by ascites. The patient was scheduled for EGD to screen for esophageal varices. EGD showed erosions and erythema in the antrum, and a deformity at the pylorus with a mucosal bridge across the pylorus [Figure 1] consistent with DP. Endoscope was passed through both openings, both of which lead to the duodenal bulb. There was no evidence of esophageal varices, gastric or duodenal ulcers. Biopsies were obtained from the stomach which were negative for Helicobacter pylori. The patient had a recent hospitalization for septic shock and acute kidney injury. Based on this, it was hypothesized to be an acquired DP secondary to possible stress ulceration from recent acute illness.3090 Figure 1. Esophagogastroduodenoscopy showing double pylorus.Majority of cases of double pylorus (DP) are acquired. Acquired cases of double pylorus are commonly secondary to a gastric ulcer that erodes and creates a fistula between the lesser curvature of the gastric antrum and the duodenal bulb. Patients with diseases resulting in chronic inflammation or an attenuated healing response are at a greater risk for the development of a DP. Our patient likely had stress ulceration during recent septic shock. The patient also had history of chronic alcohol use which has been reported to cause delayed ulcer healing and likely contributed to development of DP. Treatment of DP includes anti-acid secretion therapy with proton pump inhibitors and surgery is reserved for patients with refractory symptoms. Previously, double pylorus has rarely been reported in patients with cirrhosis. Our case along with other such reports raise the possibility that presence of underlying cirrhosis might lead to delayed ulcer healing, hence leading to DP. It is important for gastroenterologists to be aware of this condition and be cautious when using a side viewing endoscope.