The Double Pylorus

Abstract

88 year female with medical history of hypertension, type 2 diabetes mellitus, hyperlipidemia, osteoarthritis, gastroesophageal reflux disease and a vague history of peptic ulcer disease (PUD) presented to emergency department with 2 episodes of black stool and increasing fatigue over the past 3 days. She also reported using ibuprofen regularly for osteoarthritic related symptoms. Physical exam and basic laboratory investigations were also normal with the exception of hemoglobin, which was 7g/dL. Esophagogastroduodenoscopy (EGD) demonstrated a large non-bleeding ulcer (15mm in largest dimension) in the antrum. Notably, there was also a second luminal opening between the antrum and duodenal bulb adjacent to the ulcer consistent with a double pylorus (see Fig. 1 and Fig. 2). Double pylorus is a rare endoscopic finding, found in 0.001% to 0.4% of EGD. It is characterized by two openings between the distal stomach and the duodenal bulb. It can be classified as congenital or acquired based on etiology. Congenital double pylorus is usually found in association with other congenital anomalies like heterotopic pancreatic tissue, pancreatic divisum or gastric duplication. The acquired double pylorus (ADP) is usually associated with PUD and results from a prepyloric ulcer or duodenal bulb ulcer eroding into the duodenum or stomach creating a fistulous opening. Additionally, the use of NSAIDS, corticosteroids and persistent H. pylori infection can affect the healing of ulcers and can lead to ADP. Diagnosis is made by endoscopy or occasionally by radiography with the lesser curvature of stomach being the most common location of these fistulous openings. Double pylorus should be differentiated from a gastric diverticulum during endoscopy and can also be mistaken with a large mucosal fold, tumor or polyp during evaluation with upper gastrointestinal series. Treatment of double pylorus consists of promotion of mucosal healing with proton pump inhibitor and less commonly H2 blockers, avoidance of NSAIDS/corticosteroids, and treatment of H. pylori infection. The majority of fistulas do not close (or may only partially close), however endoscopic division of the bridging tissue with a sphinterotome should be considered for patients presenting with gastric outlet obstruction. Surgical intervention is an option for patients with obstruction refractory to endoscopic treatment or the presence of other complications such as perforation or refractory bleeding.Figure: Second luminal opening between the antrum and duodenal bulb adjacent to the ulcer consistent with a double pylorus.Figure: Second luminal opening between the antrum and duodenal bulb adjacent to the ulcer consistent with a double pylorus.