S6470 Acquired Double Pylorus as a Sequela of NSAID Use, Alcohol, and Helicobacter pylori

Introduction: Double pylorus, or gastroduodenal fistula, is a rare, acquired complication of peptic ulcer disease (PUD) involving an additional tract between the distal stomach and the duodenal bulb. This condition is most often associated with Helicobacter pylori infection, chronic nonsteroidal anti-inflammatory drug use, and other contributors to impaired mucosal healing. Its incidence ranges from 0.001% to 0.4% on endoscopy, and it is typically discovered incidentally, though it may occasionally present with bleeding. Case Description/Methods: A 64-year-old man with hypertension, hyperlipidemia, and chronic alcohol use disorder presented with syncope and hematemesis. He reported several days of melena and postprandial epigastric discomfort relieved by food. He endorsed frequent ibuprofen use and daily alcohol intake. On admission, he was hypotensive and tachycardic, with hemoglobin 7.3 g/dL. He received intravenous fluids, packed red blood cell transfusion, and IV pantoprazole. Upper endoscopy revealed a large cratered pre-pyloric ulcer with a secondary opening that allowed passage of the scope into the duodenal bulb, consistent with a gastroduodenal fistula. There was no active bleeding or stigmata. Gastric biopsies showed chronic active gastritis with H. pylori identified on immunohistochemistry. He was discharged on bismuth-based quadruple therapy and proton pump inhibitors, with a plan for repeat endoscopy in 8 weeks. Discussion: This case illustrates a classic but uncommon complication of peptic ulcer disease resulting from synergistic mucosal injury due to H. pylori, nonsteroidal anti-inflammatory drug use, and alcohol. Double pylorus often signifies chronic ulceration and impaired healing but is frequently asymptomatic. Its recognition should prompt eradication of risk factors and close endoscopic follow-up. Although typically managed conservatively, endoscopic or surgical intervention may be necessary if complicated by bleeding, obstruction, or refractory symptoms. Awareness of this finding is critical to guide appropriate therapy and prevent recurrence.