Acquired double pylorus or gastroduodenal fistula. Report of a case and review of the literature

Gastric ectopic pyloric opening: an unusual case

Stomach is the most dilated part of the digestive tube. The shape of the stomach could vary frequently without any clinical symptoms. Abnormality of pylorus including double pylorus and congenital pyloric stenosis has been reported but pyloric ectopic opening has not been reported before. We found a rare case of pyloric ectopic opening in the stomach body with a "hammer" shape stomach in a 72-year-old man. The patient complained of upper left abdominal with no past medical history or surgery history. The double-contrast examination showed a "hammer" shape stomach, with the pylorus opening high at the lesser curvature and enlarged distal end of the stomach. The gastrointestinal endoscopy showed that the pyloric antrum was approximately 3 cm below the cardia with a round and poor functioning opening. No obvious abnormalities in the bulb and descending part of the duodenum were observed. A large ulcer with whitish exudate covering the base was found on the posterior wall. Histological examination of the ulcer showed broken mucosal glands with atypical hyperplasia and focal carcinogenesis. This case shows a probably congenital pyloric ectopic opening in the gastric body with a "hammer"-shaped stomach, adding a new gastric morphological variation.

Clinical characteristics of double pylorus

BACKGROUND

Double pylorus can occur as either a congenital abnormality or an acquired complication of peptic ulcer disease. There has been no report of long-term follow-up of a large series of patients treated for double pylorus. The objective of this study was to determine the course of double pylorus in 20 patients by serial endoscopic examination.

METHODS

Among 102,958 endoscopic examinations conducted from 1987 to 1999, a diagnosis of double pylorus was made in 20 patients, 18 of whom were followed from 2 months to 10 years. The demographics, clinical presentations, and outcome, as well as endoscopic patterns of double pylorus, were retrospectively reviewed. The rates of ulcer recurrence and symptoms were estimated and compared.

RESULTS

Most fistulous rings were located on the lesser curve of the gastric antrum (75%). Evolution from an original ulcer to fistula was observed in 9 patients. The fistula disappeared in 1 patient, remained open in 12, and converged with the normal pyloric ring in 5 patients. One or more associated systemic diseases and extensive treatment with various drugs were noted in 12 patients. Eradication of Helicobacter pylori in infected patients resulted in a lower percentage of patients with symptoms (36% vs. 100%) and ulcer recurrence (55% vs. 100%) compared with uninfected patients, but the differences were not statistically significant.

CONCLUSION

In this study, fistula closure did not occur in the majority of patients. Associated systemic diseases and extensive use of medications might be important factors in persistence of double pylorus. Eradication of Helicobacter pylori was not beneficial in terms of relief of symptoms, prevention of ulcer recurrence, and fistula closure. Surgical intervention should be considered for patients with refractory symptoms, recurrent ulcers, and other complications.

Double pylorus: case report and review of the literature

Double pylorus is an unusual condition in which a double communication between the gastric antrum and the duodenal bulb occurs. It may be congenital, or it may be acquired complication of peptic ulcer disease. We present a case of double pylorus in a gentleman with epigastric pain and previous history of peptic ulcer disease. The relationship between Helicobacter pylori and this disease was assessed. A review of the literature, the role of associated diseases and the role of H. pylori are discussed.

Double lumen esophagus: presentation of esophagogastric fistula, a rare complication of fundoplication

A double lumen of the distal esophagus, a presentation of an esophagogastric fistula, was found in a patient who previously had an esophageal ulcer following a Nissen fundoplication. Only one other patient in our endoscopic experience of 24 years and 37,808 endoscopies has had this complication. Another patient was found to have an esophagogastric fistula, but it was associated with carcinoma. By contrast, in the 490 patients who had a Nissen fundoplication performed from 1960 to 1983, 23 (4.7%) developed an endoscopically proven esophageal ulcer. Therefore, although a double-lumen esophagus is a rare complication after a Nissen fundoplication, ulceration uncomplicated by an esophagogastric fistula is more common. Presenting symptoms of an esophagogastric fistula may be variable, but our patient, as well as two previous case reports, had dysphagia. The diagnosis is suggested radiologically and established endoscopically.

Gastric carcinoma presenting as double-channel pylorus on upper gastrointestinal series

A double-channel pylorus or gastroduodenal fistula is a rare entity frequently acquired in association with penetrating peptic ulcer disease. The diagnosis is made by upper gastrointestinal series or by endoscopy. We report a 59-year-old man who presented with gastric outlet obstruction whose upper gastrointestinal series was typical of benign peptic ulcer disease demonstrating antral ulcers and a double-channel pylorus. At operation, gastric carcinoma infiltrating the pyloric channel and dividing it into two lumens was found. No gastroduodenal fistula was found. The "gastroduodenal fistula" on upper gastrointestinal series had been created by gastric carcinoma protruding into the pyloric channel and dividing the barium flow into two streams. One can no longer assume that a double-channel pylorus is due to benign ulcer disease.

The clinical significance and natural history of the double pylorus

The double pylorus is a fistulous communication between the gastric antrum and duodenal bulb. In most instances, it is believed to be a complication of peptic ulcer disease. In prior reports, the longest follow-up has been only 5 years. We report four cases of double pylorus, three of which have been followed medically (one for 7 years), and a fourth which required surgery for recurrent pain after 10 years of medical treatment. In previously reported cases, only 20% have required surgery, usually for refractory symptoms, whereas 80% of patients have been managed medically and have been free of complications. In one of our cases, the mucosal bridge separating the pylorus from the fistula perforated, with coalescence of the two channels into one large gastroduodenal passage. There were no serious clinical symptoms or sequelae caused by this additional destruction of tissue. We conclude that the double pylorus is a destructive but relatively benign complication of peptic ulcer disease.