A 58-year old man who was undergoing treatment for an oropharyngeal carcinoma was
experiencing significant dysphagia and underwent endoscopy for placement of a percutaneous
endoscopic gastrostomy (PEG) tube. Examination of the stomach revealed superficial
erosions consistent with mild antral gastritis, and a double-pylorus deformity was
identified (Fig. [1]).
Figure 1 Double pylorus observed in a 58-year-old man during endoscopy for placement of a percutaneous
endoscopic gastrostomy.
A 57-year-old man with a remote history of peptic ulcer disease presented for endoscopy
with a 2-month history of intermittent epigastric abdominal pain. Examination of the
stomach revealed a double-pylorus deformity (Fig. [2]).
Figure 2 Double pylorus observed in a 57-year-old man undergoing endoscopy due to abdominal
pain.
During upper gastrointestinal endoscopy, the discovery of two pyloric ostia leading
into the duodenum, also known as double pylorus, is a rare and surprising finding
that has been reported in 0.001-0.4 % of procedures [1]. In a review of 60 cases of double pylorus, Eschar et al. found that the mean age
of the patients was 59.6 years (range 28-89 years) and that double pylorus was more
common in men (62 %) [1]. The underlying etiology of double pylorus is either congenital or acquired. A diagnosis
of congenital DP depends on both channels having normal histology, with no signs of
antroduodenal ulceration or inflammation. Acquired double pylorus is more commonly
observed, and arises from ulceration and fistulization between the gastric antrum
and duodenal bulb; not all of the normal histological layers are present in this form
[2]. Less commonly, double pylorus can arise due to ulceration from a gastric or duodenal
malignancy that eventually becomes a fistula [3]. Not surprisingly, many patients with double pylorus present with a long-standing
history of symptomatic peptic ulcer disease [1]
[2]. In contrast swallow studies, double pylorus appears as two channels of barium separated
by a smooth radiolucent band of soft tissue. At endoscopy, the gastric antrum may
appear normal (as in the present two cases), inflamed, or ulcerated [4]. The fistula may vary in size from a few millimeters to several centimeters, and
usually extends from the lesser curvature of the stomach to the superior aspect of
the duodenal bulb [5]. Irregularity in the region of the fistula should prompt multiple directed biopsies
to rule out malignancy. From the gastric antrum, visualization of a biopsy forceps
or catheter that has been passed through the fistula and is observed to enter the
pylorus has been described as offering a useful technique for diagnosing double pylorus
[5].
Endoscopy_UCTN_Code_CCL_1AB_2AD_3AC
