The clinical significance and natural history of the double pylorus

Abstract

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.

Acquired Double Pylorus: A Case Report

“…However, he did not have the other complications, such as hemorrhage, obstruction, or perforation of the septum, previously reported in this condition. 9 The duodenal diverticulum and colonic diverticulosis found in this patient have not previously been reported in association with double pylorus and may therefore be coincidental. Although the barium studies were done first in this patient, the correct diagnosis was not made until the endoscopy.…”

“…5 However, the majority of patients with this condition are over the age of 60 years. 9 Although it is said that ulcer symptoms disappear once the fistula is formed, 8 this patient's symptoms persisted, at least during the period of follow-up, and necessitated another course of cimetidine. However, he did not have the other complications, such as hemorrhage, obstruction, or perforation of the septum, previously reported in this condition.…”

“…Kothandaraman et al 8 found 84 cases in the world literature, while Einhorn et al 9 and Eshchar et al 10 came across only 53 and 60 cases, respectively. Whatever the highest reported number may be, it is almost certainly an underestimate because of poor case identification.…”

“…This supports the view that endoscopy is the better diagnostic procedure in this condition. 9 There is general agreement that the symptoms are due to the ulcer itself and not due to the double pylorus. This patient was therefore treated with a common antiulcer regimen, an approach favored by most clinicians.…”

“…This patient was therefore treated with a common antiulcer regimen, an approach favored by most clinicians. 8,9,11 The good response to the reintroduction of cimetidine therapy obviated the need for surgical intervention.…”