S6438 Double Trouble: A Case of Double Pylorus Secondary to a Pre-Pyloric Gastric Ulcer

Introduction: In rare cases, gastric ulcerations can create a fistulous tract between the pre-pyloric stomach and duodenal bulb, resulting in a “double pylorus”. A double pylorus is seen in up to 0.4% of endoscopies and results from either a congenital or acquired deformity within the distal stomach. Risk factors include H. pylori infection, diabetes and nonsteroidal anti-inflammatory drug use. We present a rare case of double pylorus secondary to a gastric ulcer in an elderly woman presenting with ongoing abdominal bloating, vomiting, and weight loss. Case Description/Methods: A 68-year-old woman with a past history of hypertension, hyperlipidemia, osteoarthritis with intermittent Ibuprofen use and OSA on continuous positive airway pressure (CPAP) presented with a new onset of abdominal bloating, vomiting, decreased appetite, and a 5 lb weight loss. She had a recent change in her CPAP settings and felt this was attributing to her symptoms. She began taking as-needed Pepcid and Protonix and decreased her CPAP usage with improvement. Therefore, she declined further evaluation with esophagogastroduodenoscopy (EGD) and it was recommended that she increase her Protonix to 40 mg daily. She re-presented 3 months later with worsening symptoms including right upper quadrant abdominal pain, and an 11 lb weight loss. Computed tomography (CT) abdomen and pelvis with contrast was remarkable for a small hiatal hernia. EGD showed a 10 mm cratered pre-pyloric gastric ulcer. The ulcer perforated the stomach creating a fistula between the pylorus and duodenal bulb. Her Protonix was further increased to 40 mg twice daily. Biopsies were negative for H. pylori. On repeat EGD, there was a persistent medium-sized fistula in the pre-pyloric region of the stomach with communication to the duodenum and 2 localized non-bleeding erosions in the pre-pyloric region at the site of the fistula. The prior ulcerated area appeared mostly healed. Her Protonix was decreased to 40 mg daily for 3 months followed by 20 mg daily with full resolution of symptoms. Discussion: Although rare, a double pylorus can be acquired from chronic peptic ulcer disease commonly caused by an H. pylori infection or nonsteroidal anti-inflammatory drug use. It is important to complete further endoscopic workup in patients with red flag symptoms and provide comprehensive education on symptomatology associated with possible diagnoses and appropriate diagnostic testing when patients are hesitant to invasive interventions. In this case doing so ultimately led to the discovery of pre-pyloric gastric ulceration with a rare finding of gastroduodenal fistula creating a double pylorus.