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. (Gastrointest Endosc 2001;54:464-70.) Double pylorus (DP), a form of gastroduodenal fistula, consists of a short accessory canal from the distal stomach to the duodenal bulb such that the gastric antrum and bulb become connected by 2 openings separated by a septum or bridge. The fistula usually arises from the lesser curve of the gastric antrum and enters the superior aspect of the duodenal bulb. In most cases, DP is an acquired complication of ulcer disease. However, some cases have been reported in which DP was evidently a congenital anomaly.1-5 The first case of DP was detected endoscopically.6 To date, there have been sporadic reports of more than 100 cases. Most patients responded well to medical treatment regardless of whether the fistula was open or closed. However, about 20% of the patients underwent surgery because of refractory symptoms or other complications.3,5,7,8 There is no long-term follow-up study of DP.3,5,7-9 The association of DP with other systemic diseases8,9 and Helicobacter pylori infection9 is not well characterized. The clinical findings were reviewed in 20 patients with DP identified from among 102,958 endoscopic procedures performed over a period of 12 years. The pathogenesis of this disease and the effect of H pylori eradication therapy are also discussed. The aims of this study were to provide further insight into the pathogenesis of DP and to develop a treatment strategy for this condition.