An Adventurous Tract - Double Pylorus in Chronic Liver Disease

Document Type

Conference Proceeding

Publication Date

10-1-2024

Publication Title

Am J Gastroenterol

Abstract

Introduction: Double pylorus (DP) is a rare entity, with an incidence ranging from 0.02%-0.01% in all endoscopies. DP with cirrhosis is very sparse. DP exists in congenital and acquired forms. Research suggests that DP may result from poorly healing ulcers and is linked to comorbidities like diabetes, chronic obstructive lung disease, rheumatoid arthritis, cirrhosis, chronic kidney disease, and radiotherapy. Case Description/Methods: A 41-year-old man with past medical history of chronic liver disease with prior inconclusive liver biopsy, chronic kidney disease stage 3b, diabetes mellitus, presents with abdominal distention, bilateral lower limb swelling, and worsening anemia (Figure 1). On admission, labs showed normocytic anemia, negative hepatitis screen, normal alpha-1-antitrypsin levels, and non-reactive HIV test. Antibodies for liver-kidney microsomal, smooth muscle, mitochondrial M2 antibodies were normal. Family history was negative for hepato-pancreatic neoplasms, liver disease, and genetic conditions. Social history negative for intravenous drug use, high-risk sexual practices, and travel history. Model for end-stage liver disease score was 16-18. Esophagogastroduodenoscopy (EGD) showed a duplicated pylorus with multiple erosions on antral surface and ulcerations which were likely a potential cause of bleeding. The duodenal bulb did reveal multiple erosions and the post-bulbar duodenum was normal. Biopsy was positive for Helicobacter pylori in stomach and antrum. Liver biopsy showed bridging fibrosis with nodule formation consistent with Ishak 6/6, Metavir F4 Fibrosis. Discussion: The likely mechanism of DP in our patient is fistulization due to poorly healing ulcer complicated by liver cirrhosis. Treatment should prioritize addressing factors hindering proper healing. Although many cases respond well to proton pump inhibitor (PPI) therapy, surgery becomes necessary for free perforations, obstructions - that are refractory to endoscopic treatment-, and refractory bleeding. Notably, even with treatment, fistulae persist in 67%, fusion in 28%, and self-resolution in 5% of cases. This case highlights the need for heightened awareness and caution during EGD or endoscopic retrograde cholangiopancreatography in such patients to prevent procedural complications and adverse patient outcomes. Follow-up endoscopies can be performed to monitor for disease course.

Volume

119

Issue

10

First Page

S3205

Last Page

S3206

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