[The double pylorus - a rare endoscopic finding].

HISTORY AND ADMISSION FINDINGS: A 58-year-old man was admitted for elucidation of a microcytic anemia diagnosed by his general practitioner (hemoglobin of 5,5 g/dl). He felt dizzy and unwell. The patient had for some time been regularly taking 1-2 tablets of diclofenac, a nonsteroid anti-inflammatory drug (NSAID), for joint and gouty pain. He had occasionally noted small amounts of blood on his stool. The physical examination was unremarkable except for obesity, several swollen and painful joints, and a gouty right big toe with a tophus and small ulcer.

INVESTIGATIONS: Coloscopy revealed extensive multiple aphthous ulcers throughout the colon (histologically diagnosed as NSAID colopathy). Esophagogastroduodenoscopy failed to identify a source of bleeding. But it also revealed a double pylorus, which was divided into two equal parts by a smooth, pencil-thick circular band, but fully patent and without inflammatory changes or scarring.

TREATMENT AND COURSE: Several erythrocyte units were infused, which stabilized the patient's condition. There was no evidence of renewed bleeding. But subsequently he experienced severe joint pain, the CPR rising to 252.31 mg/dl. Administration of steroids, novaminsulfon and opioids, as well as uric acid lowering drugs gradually improved the joint pain and enabled physiotherapy to improve mobility and the patient was discharged home.

CONCLUSION: Congenital abnormalities are rarely found during gastrointestinal endoscopy in adults. Very rare are duplications of the pyloric channel most of which are acquired by ulcer perforation. In general, congenital double pylorus is mainly a harmless incidental finding which needs no therapy, but it should be distinguished from acquired double pylorus. Endoscopists should be aware of this abnormality to avoid complications during side-view endoscopy.