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Chapter 31 (page 154)
Einhorn et al. (1984) reviewed the literature of acquired double pylorus and reported 4
new cases with long term follow-up. In 36 cases the fistula extended from the lesser
curvature of the "antrum" to the superior portion of the duodenal bulb. In 28 of these it had
originated from "antral" ulcers, in 2 from "pyloric channel" ulcers and in 6 from duodenal
ulcers. In 9 cases the fistula was situated between the greater curvature and the inferior
portion of the duodenal bulb, 7 originating from antral ulcers, one from a pyloric channel
ulcer and one from a duodenal ulcer. The radiological appearance of a double pylorus
was said to be characteristic, consisting of two channels of barium separated by a smooth
band of soft tissue which represented the intervening mucosal septum. The endoscopic
appearance was also typical, the aperture of the fistula being clearly visible in the
majority of cases. With the endoscope in the "distal antrum", it was frequently possible to
insert a biopsy instrument into the fistula and visualize its tip within the duodenum by
viewing through the pylorus.
None of the cases of acquired double pylorus reported up to 1984 had been associated
with malignancy (Einhorn et al. 1984). Friehling and Rosenthal (1985) subsequently
described an unusual case of gastric carcinoma in which the radiological appearance of a
double-channel pylorus was the result of partition of the pyloric aperture by the tumor, no
fistula being present.
The radiological features of two more (unconfirmed) cases of benign, acquired pyloro-
duodenal fistula were subsequently described by Hurwitz and Friedman (1987).
Acquired double pylorus or pyloro-duodenal fistula occurring as a result of perforation of
a peptic ulcer has also been known by the terms pseudo-pylorus, tunnel ulcer, pyloric
diaphragm, antral mucosal band and pyloric septum (Drapkin et al. 1974; Hegedus et al
1978). None of the authors quoted, with the exception of Keet and Bezuidenhout (1984),
described the condition in relation to the concept of the pyloric sphincteric cylinder.
Our cases had the following features in common: In all the pyloro-duodenal fistula
extended from the superior aspect of the distal part of the pyloric sphincteric cylinder to
the superior fornix of the duodenal bulb, i.e. it was situated on the lesser curvature side.
(As reported in the literature the fistula may occasionally occur on the greater curvature
In all 4 cases the sphincteric cylinder remained partially contracted (or, in other words,
incompletely expanded) throughout the radiological examination; although minor
degrees of contraction and relaxation did occur, these movements were never maximal.
This is best illustrated in Fig. 31.2, in which a permanent contraction of the left pyloric
loop on the greater curvature, opposite the commencement of the fistula, is seen. In Case
31.4 the contraction at times reached the pseudo-diverticulum stage (Fig.
31.4B), before reverting to incomplete expansion (Fig. 31.4A).
It is concluded that our cases of acquired pyloro-duodenal fistula were associated with
motility disturbance of the pyloric sphincteric cylinder, consisting of a restriction in the
range of contraction and relaxation. Theoretically this could have an effect on emptying
and trituration of solids (Chap. 18). Emptying of liquid barium occurred without undue
delay through both orifices.
- Bender MD, Soffa DJ. Acquired double pylorus: a case report.
Radiology l975, 116, 325-326.
- Drapkin RL, Otsuka AL, Castellanos HL et al. Acquisition of a pyloric septum or
pyloric duodenal fistula. Gastroenterology l974, 66, 1234-1236.
- Einhorn RI, Grace ND, Banks PA. The clinical significance and natural history of
the double pylorus. Dig Dis Sci l984, 29, 213-218.
- Engle R. Tunnel ulcer with double pyloric canal. Radiology l975,
- Friehling JS, Rosenthal LE. Gastric carcinoma presenting as double-channel
pylorus on upper gastrointestinal series. Dig Dis Sci l985, 30, 269-
- Hansen HO, Kronborg O, Pedersen T. The double pylorus. Scand J
Gastroenterol l972, 7, 695-696.
- Hegedus V, Poulsen PE, Reichardt J. The natural history of the double pylorus.
Radiology l978, 126, 29-34.
- Hurwitz J, Friedman L. Pyloroduodenal fistula: a benign complication of peptic
ulcer disease. South Afr Med J 1987, 72, 56-58.
- Keet AD, Bezuidenhout DJJ. Dubbele pilorus en piloroduodenale fistels.
South Afr Med J l984, 66, 740-742.
- Tallman JM, Clements JL, Gilliam JH, et al. The multi-channelled pylorus.
Clin Rad l979, 30, 337-341.
- Thompson WM, Kelvin FM, Gedgaudas RK, et al. Radiologic investigation of
peptic ulcer disease. Rad Clin North Amer l982, 20, 701-720.
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