TO THE EDITOR:
We would like to share an unusual case of an older woman who had a double pylorus appearance seen during endoscopy. A 63-year-old woman was admitted for hematemesis and melena for 2 days. Physical examination revealed tachycardia of 110 beats per minute and a systolic blood pressure of 90 mmHg. A full blood count revealed a hemoglobin level of 5.2 g/dl with normal platelets and prothrombin time. The patient was resuscitated with crystalloids and three units of packed red blood cells. High-dose intravenous proton-pump inhibitor therapy was started. After achieving a stable hemodynamic state, upper endoscopy was performed.
Endoscopic examination of the stomach revealed hiatal hernia with cameron ulcers and two channels in the pylorus region, with a clean based ulcer at the bulber side and an ulcer scar at the gastric side of the acquired channel (Figure 1). The endoscope could be passed through both of the ducts, from the antrum to the duodenal bulb. There was no evidence of active bleeding; therefore, no therapeutic endoscopic procedure was performed. Biopsies of the ulcerative region of the hernia showed an active chronic gastritis with Helicobacter pylori. Following this, treatment for Helicobacter pylori infection was started with amoxicillin clarithromycin and lansoprazol. The patient was discharged after 2 days of observation. During the 2 months outpatient follow-up period, rebleeding was not observed.
For this patient, a fistula arising between the stomach and duodenal bulb resulted in the appearance of a double pylorus, which is first described in 1969 by Smith and Tuttle (1969). A double pylorus is a rare endoscopic finding that has been reported in 0.001%-0.4% of upper gastrointestinal endoscopies. In most cases, it is a complication of peptic ulcer disease (Hegedus, Poulsen, & Reichardt, 1978; Hu et al., 2001). It may occur as a congenital abnormality or secondary to gastric carcinoma (Matsuyama, Nagashima, Watanabe, & Takahashi, 2001; Mylonas et al., 2002). It is seen more frequently in males, more common in the lesser curvature of the gastric antrum, and connects to the superior wall of the duodenal bulb (Hegedus et al., 1978; Hu et al., 2001).
Most patients respond well to antiulcer medication without surgical intervention. Surgical treatment is necessary only in patients unresponsive to medical and endoscopic treatment (Hu, Tai, Changchien, Chen, & Chang, 1995; Mcgrew, Spear, Sutton, & Dunn, 1984). Gastrointestinal healthcare providers should be aware that double pylorus appearance usually occurs as a complication of peptic ulcer disease.
Sincerely,
Abdurrahim Sayilir, MD
Mevlut Kurt, MD
Ibrahim K. Onal, MD
Yavuz Beyazit, MD
Burak Suvak, MD
Department of Gastroenterology,
Turkiye Yuksek Ihtisas Teaching and Research Hospital,
Ankara, Turkey.
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