DISCUSSION

Double pylorus is a rare disease, with a reported prevalence of between 0.06% and 0.4% ⁽³⁾.

This abnormality is often associated with stomach and duodenum peptic ulcer disease, stomach malignancy, respiratory system diseases, chronic kidney disease, and diabetes mellitus. A long history of treatment with drugs including corticosteroids and NSAIDS may also prohibit healing, leading to fistula formation ⁽⁴⁾.

This patient had none of these concomitant diseases nor used medications, but he was positive for H. pylori, which is known to be responsible for recurrent refractory ulcers. Although the association between double pylorus and H. pylori has not yet been elucidated, this infection may have played a role in forming the fistula in our case. In order to prevent new ulcer formation and to improve the healing of the fistula, eradication of H. pylori may be recommended for this condition ^(5-8).

The diagnosis is usually made by endoscopy ^(1,9). Our patient’s history of recurrent epigastric pain and dyspepsia suggests that the lesion was acquired and arose from the antral ulcer, penetrating to the duodenal bulb.

There are some case reports of symptomatic double pylorus causing epigastric discomfort, dyspepsia and upper gastrointestinal hemorrhage ⁽⁶⁾. However; this condition generally does not exhibit any symptoms. In fact, it is mostly found serendipitously by endoscopic or x-ray examination ⁽⁷⁾, considering the clinical course, our patient’s symptoms were probably due to peptic ulcer.

The management of double pylorus is usually conservative with anti-ulcer therapy. Nevertheless, ulcer healing in these patients is usually poor. Surgical intervention such as distal gastrectomy should only be considered for patients with refractory symptoms, recurrent ulcers and complications ⁽⁶⁾.

Very often the accessory pylorus channel remains for life, but in some patients it closes or connects with the true pylorus to form one channel again ⁽¹⁰⁾.

According to the study reported by Hu et al, the double pylorus closed in 9%, remained open in 64%, and eventually fused or formed a single large pylorus in 27% of patients ⁽⁶⁾.

In summary, double pylorus is a rare condition, as well as a relatively benign complication of peptic ulcer. It should be treated with proton pump inhibitors and a long follow up, as some patients do not have a good response for clinical treatment.

Conflict of interests:

None.

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