Journal of the Pancreas Open Access

Keywords

Pancreas; Complications; pylorus

Dear Sir,

Double pylorus (DP) is a rare condition that is usually discovered incidentally through an upper endoscopy (UE) examination. While acquired DP, which is the most common type, often develops as a complication of peptic ulcer disease (PUD), congenital DP can be isolated associated with other congenital abnormalities such as heterotopic pancreatic tissue or gastric duplication [1, 2]. This article presents the first case of DP associated with pancreas divisum (PD).

A twenty two-year-old woman was admitted to our hospital because of mild epigastric pain. Her medical history was unremarkable. The laboratory tests that were requested on admission were normal except for amylase 920 U/L (reference range: 60-180 U/L).The patient denied having had any history of PUD or of having used nonsteroidal anti-inflammatory drugs (NSAIDs). A UE examination revealed two pyloric openings into the duodenal bulb. However, there was no evidence of PUD on the UE. The presence of Helicobacter pylori was not observed in the histologic examination of the gastric antrum tissue. Magnetic resonance cholangiopancreatogram (MRCP) imaging showed PD (Figure 1 A-B). The patient was treated symptomatically, and she recovered. When the UE and MRCP were repeated for control on the sixth month of the treatment, they demonstrated the same findings as the initial UE and MRCP.

Figure 1. A) Endoscopic appearance of double pylorus, B) MRCP appearance of pancreas divisum. Typically, the accessory duct drains majority of pancreas (white arrow).

DP is a rare condition consisting of a double communication between the gastric antrum and the duodenal bulb [3]. The condition has a reported endoscopic incidence between 0.02% and 0.08% [1, 4]. In an extensive literature review of all gastrointestinal tract duplications published in English literature, DB was found in only 1 out of 281 reported cases [5]. The coexistence of pancreas divisum and gastric duplication has also been reported by Di Pisa et al. [6].

In our case, the MRCP showed ventral duct draining of the pancreas. Because of the normal mucosal findings of the gastric antrum and the duodenal bulb on the UE, as well as the negative history of PUD or of any use of NSAIDS, we diagnosed this patient as having DP associated with PD.

To our knowledge, we are reporting the first case in which double pylorus and pancreas divisum occurred at the same time. Consequently, double pylorus might be included in the list of complications that are seen with pancreas divisum.

Conflict of interest

The author declared no conflict of interest.

References

1. Hu TH, Tsai TL, Hsu CC, Lu SN, Hsiao M, Changchien CS. Clinical characteristic of double pylorus. GastrointestEndosc 2001; 54: 464-470. [PMID: 11577308]
2. Archampong EQ, Blanchard RJ, Boult I. Double channel pylorus: Congenital or acquired? Can J Surg. 1981; 24: 537-539. [PMID: 7284920]
3. Safatle-Ribeiro AV, Ribeiro Junior U, Habr-Gama A, Gama-Rodrigues JJ. Double pylorus: case report and review of literature. Rev HospClinFac Med 1999; 54: 131-134. [PMID: 10779821]
4. Goh BK, Tan HK. Double pylorus. American Journal of Surgery 2006; 191: 515-516. [PMID: 16531146]
5. Macpherson RI. Gastrointestinal tract duplications: clinical, pathologic, etiologic, and radiologic considerations .Radiographics 1993; 13: 1063-1060. [PMID: 8210590]
6. Di Pisa M, Curcio G, Marrone G, Milazzo M, Spada M, Traina M. Gastric duplication associated with pancreas divisum diagnosed by a multidisciplinary approach before surgery. Worl J Gastroenterology 2010; 16: 1031-1033. [PMID: 20180246]