Acquired double pylorus: Clinical and endoscopic characteristics and four-year follow-up observations

Abstract

Double pylorus (DP), or duplication of the pylorus, is an uncommon condition that can be either congenital or acquired. Acquired DP (ADP) occurs when a peptic ulcer erodes and creates a fistula between the duodenal bulb and the distal stomach. The clinical features and endoscopic characteristics of four patients with ADP were reviewed and compared with previously reported cases. An accessory channel connects the lesser curvature of the prepyloric antrum with the duodenal bulb, and in all cases, a peptic ulcer was located in or immediately adjacent to the accessory channel. In one of the patients, the bridge between the double-channel pylorus disappeared, resulting in a single large opening and duodenal kissing ulcer after two years and three months. Finally, nonsteroidal anti-inflammatory drugs, Helicobacter pylori and other risk factors associated with ADP are assessed.

Keywords: Acquired double pylorus; Gastrointestinal hemorrhage; Helicobacter pylori; Nonsteroidal anti-inflammatory drugs; Peptic ulcer.

Figure 1

Double pylorus observed. A: A 41-year-old man undergoing endoscopy due to epigastric pain. A yellow-based irregular ulcer (arrowhead) is present in the antrum of the lesser curve over the accessory pylorus (dotted arrow). The solid arrow indicates the true pylorus; B: A 61-year-old man with osteoarticular degenerative disease who underwent endoscopy due to melena. A white-based ulcer (arrowhead) with edematous margins within the accessory pylorus (dotted arrow) on the lesser curve of the peri-pyloric region is present. The other opening is the normal pylorus (solid arrow); C: A 58-year-old man with headache who underwent endoscopy due to coffee-ground vomitus and melena. A white-based deep ulcer (arrowhead) is present in the anterior wall of the gastric antrum on the left side of the accessory pylorus (dotted arrow). The solid arrow indicates the true pylorus. D: A 62-year-old woman with gout who underwent endoscopy due to abdominal pain. A white-based ulcer (arrowhead) within the accessory pylorus (dotted arrow) is visible. The other opening is the true pylorus (solid arrow). Severe erythematous gastritis of the antrum is also present.

Figure 2

Gastric fundus mucosal congestion, erosion, active bleeding and an irregular hematin-based shallow ulcer within the thin white fur (arrow) in the 58-year-old man who underwent endoscopy due to coffee-ground vomitus and melena. Prior to the occurrence of the melena, the patient had ingested 8 bags of TouTongFen.

Figure 3

Two years and three months after the first endoscopic exam. A: The bridge between the two channels had disappeared, with a single large pylorus (solid arrow) observed in the woman with gouty arthritis. The arrowhead indicates the duodenal posterior wall ulcer; the dotted arrow indicates the descending duodenum; B: A clean-based duodenal kissing ulcer was observed in the woman with gouty arthritis. The arrowhead indicates the anterior wall ulcer. The dotted arrow indicates the posterior wall ulcer in the duodenum, and the solid arrow indicates the descending duodenum.