Acquired double pylorus, due to penetrating gastric ulcer, presenting with melena

Abstract

Acquired double pylorus (DP) is an uncommon condition consisting of two communicating channels between the gastric antrum and the first part of duodedum. Little is known about the origin of DP. As there is no specific gastrointestinal symptom due to DP, most often it is diagnosed by gastroscopy while performing for other indicationsFew data are also known about the clinical course of DP. In the patients with peptic ulcer symptoms, the pyloroplasty-like drainage effect, improving gastric emptying after the estabilishment of the fistula, could relieve these symptoms. This represents an unresolved issues about the necessity of repeating endoscopy to document in the patients with DP its final outcome, as the risk of ulcer recurrence. We describe a case of a 76-years-old woman admitted to our department for hyposideremic anemia associated to a recent history of melena.

Key Words: Double pylorus; Gastric ulcer

INTRODUCTION

Acquired double pylorus (DP) is an uncommon condition (less than 0.4% of gastroscopies)[1,2] consisting of two communicating channels between the gastric antrum and the first part of duodedum. It represents often an incidental finding at the upper endoscopy, when this is performed for other indications[3], and because of its rarity few data are available about its clinical course and consequently about the way to follow up this endoscopical entity. We describe a case of a 76-years-old woman with hyposideremic anemia, associated to a recent history of melena, in which an upper endoscopy showed an acquired double pylorus, due to penetrating gastric ulcer.

CASE REPORT

We describe a case of a 76-years-old woman admitted to our department for hyposideremic anemia (Hb 5 g%) associated to a recent history of melena. A gastroscopy was performed, showing a fistula, into the antral superior wall, between the prepyloric antrum and the duodenal bulb, with hyperaemic stigmata into the mucosa associated with scarred sign, typical of past penetrating ulcer (Figure 1). Hystology of the antrum showed the features of mild chronic erosive gastritis Helicobacter pylori (HP) positive. Upper gastrointestinal series were performed, but they were not diagnostic because repeated vomiting of the patient during the exam; despite they did not confirm the presence of a DP, the visualization of an eccentric pylorus could be compatible with the gastro-duodenal fistula seen at the gastroscopy (Figure 2). A colonoscopy did not show any source of bleeding. After three blood transfusions, the patient was discharged with a triplex HP eradication therapy and a procinetic, with disappearance of melena and improvement of Hemoglobin value (10 g %). Urea breath test was performed one month later, showing the eradication of HP infection. Normal haemoglobin levels and the absence of gastrointestinal symptoms were noted on follow-up.

Figure 1 A fistula, into the antral superior wall, between the prepyloric antrum and the duodenal bulb, with hyperaemic stigmata into the mucosa associated with scarred sign, typical of past penetrating ulcer.

Figure 2 The visualization of an eccentric pylorus.

DISCUSSION

Little is known about the origin of DP. As there is no specific gastrointestinal symptom due to DP, most often it is diagnosed by gastroscopy while performing for other indications[3]. The radiological features are characteristic: there are two channels connecting the gastric antrum to the superior fornix of the duodenal bulb, while the fistula usually arises from the lesser curvature of the antrum. Despite this, it is sometimes difficult to distinguish between double pylorus and marked pyloric deformity[4]. Association with HP has been observed in other case report series[5,6], while other authors reported that double pylorus could be an extremely uncommon presentation of gastric adenocarcinoma[7].

Few data are also known about the clinical course of DP. In the patients with peptic ulcer symptoms, the pyloroplasty-like drainage effect, improving gastric emptying after the estabilishment of the fistula, could relieve these symptoms[4]. Hu et al[2] noted that majority of the cases of DP treated with eradication therapy for HP remained open. This represents an unresolved issues about the necessity of repeating endoscopy to document in the patients with DP its final outcome, as the risk of ulcer recurrence.