A 65-year-old woman presented with right lower quadrant (RLQ) abdominal pain of three days duration. During her hospitalization, she underwent computed tomography (CT) of the abdomen, duplex ultrasound of the abdomen, esophagogastroduodenoscopy (EGD), and colonoscopy as part of a diagnostic workup. The workup identified high-grade obstructions of the celiac artery (CA), superior mesenteric artery (SMA), atypical appearing gastric ulcers, and a diffusely ulcerated cecum, which created a mass-like appearance. The patient developed cecal perforation despite mesenteric vessel stenting and ultimately required right hemicolectomy for definitive management. This case report represents a rare presentation of simultaneous gastric ischemia and cecal ischemia with necrosis in a patient with underlying peripheral vascular disease.

INTRODUCTION: Double pylorus is a rare endoscopic finding that has been reported in 0.001% to 0.4% of upper gastrointestinal endoscopies, consisting of a gastroduodenal fistula extending from the prepyloric gastric antrum to the duodenal bulb through an accessory channel. In the majority of cases, it is a complication when peptic ulcers erode and create a fistula between the duodenal bulb and the distal stomach. It usually presents on the lessor curvature of the gastric antrum and on a superior wall of the duodenal bulb. It is commonly an endoscopic finding, since clinical presentation is similar to other peptic diseases. CASE DESCRIPTION/METHODS: The patient was a 62-year-old female presented to the emergency room for evaluation of intractable nausea and vomiting. The patient reported sudden onset of symptoms day prior, with multiple episodes of brown-colored liquid emesis. Patient denied any associated abdominal pain, no postprandial association with food. CT showed significant mucosal thickening of the gastric antrum to proximal duodenum, resulting in severe dilation of the stomach with air fluid level. Nasogastric tube was then placed for decompression and serial KUB showed adequate position and non-obstructive bowel gas pattern. An esophagogastroduodenoscopy revealed moderate gastritis and antral duodenal fistula, an accessory channel was noted on the lesser curvature side and once engaged was able to be passed with the endoscope. Pathology returned reactive mucosal changes suggestive of focal erosions, Helicobacter Pylori returned negative. DISCUSSION: The majority of reported cases of double pylorus are acquired and are attributed to complications of ulcers at the antrum-pyloric area or at the duodenal bulb. Acquired double pylorus typically present symptomatic with chronic upper abdominal pain, vomiting, dyspepsia, or upper gastrointestinal bleeding. Patients often have a long history of treatment with NSAIDs or corticosteroids, which should prompt an investigation for Helicobacter pylori and eventual treatment if found positive. Medications for the reduction of peptic acid should be taken and ulcerogenic medications should be avoided. The majority of patients respond well to medical treatment, according to a retrospective follow-up study in patients treated with H2 receptor antagonist or proton pump inhibitor after the diagnosis of acquired double pylorus, the fistula remained open in the majority of patients (64%), fused with normal pylorus in 27% of patients and closed only in 9% of cases.