A 61-year-old man was presented to our department with epigastric discomfort, general weakness, weight loss (~14 kg in 4 months), constipation, melena and vomiting for the last 4 months of solid intake 1 h after each meal. There was a good tolerance to liquid intake.\nPhysical examination revealed that the patient was afebrile, slightly pale, hemodynamically stable with no jaundice. We noticed an abdominal scar of midline incision and a mild tenderness in epigastrium. No organomegaly was found.\nPreviously, 1 month ago, the patient was admitted for the same complaints. He underwent upper gastrointestinal endoscopy which was unsuccessful because of the residual food in his stomach. The patient was put on omeprazole 20 mg twice daily with a re-evaluation after a month.\nThe patient’s past surgical history included perforated benign first portion of duodenal ulcer 15 years ago (treated by primary closure and graham patch) and cholecystoctomy with no other significant medical history.\nAdmission work-up is shown in Table .\nAn upper gastrointestinal endoscopy was performed again after having the patient fast overnight with these findings (Fig. ): residual food in stomach, pyloric edema and severe stenosis of the bulb that prevented us from progressing further into the small intestine. Biopsies were taken from the bulb and the atrophic mucosa of antrum. Histopathology revealed mild chronic atrophic gastritis and non-specific chronic duodenitis with no findings of either helicobacter pylori infection or malignancy. Colonoscopy, on the other hand, was within normal.\nIntravenous contrast computed tomography showed thickening of proximal gastric and pyloric walls and a mild dilatation of extra- and intra-hepatic bile ducts, although the head of pancreas was normal (Fig. ).\nThe primary diagnosis was gastric outlet obstruction due to a complicated benign duodenal ulcer. The diagnosis was based on the benign endoscopic histopathology findings of the bulb and the rarity of duodenal malignancy. The decision then was to perform elective laparotomy because of both refractory symptoms despite of medical treatment with proton pump inhibitors and the lack of medical experience in endoscopic dilation in the hospital. During surgery, we found severe adhesions caused by the previous surgery which required careful adhesiolysis. The stomach was dilated and thick-walled. A stenosis of duodenal bulb was also detected. Surprisingly, we palpated a mass (5 × 7 cm) arising from the posterior lower half of greater curvature extending to the lesser sac. Anatomically, this mass (Fig. ) represents a gastro-duodenal fourth segment fistula.\nThe surgical steps were (Fig. ): Antrectomy, resection of the fourth duodenum, end to end third duodenojejunostomy, Omega-Braun gastrojejunostomy, feeding jejunostomy and drainage. Histopathology study revealed a perforated benign gastric ulcer (Fig. ).\nWith a strict post-operative follow-up (shown in Table ) for the patient, he was discharged home in 9 days.
We present a 66-year-old female who presented to surgical outpatient department with mild epigastric pain. She denied any history of peptic ulcer disease or use of ulcerogenic drugs, such as NSAIDs. Clinical examination revealed an otherwise fit patient; the abdominal examination was normal. The endoscopy showed no evidence of peptic ulceration but demonstrated a double pylorus (). The mucosa of the stomach as well as the duodenum appeared normal. The duodenum was easily entered via both pyloric channels. The patient was treated symptomatically and is now well. A follow-up endoscopy 6 weeks later demonstrated the same findings as the initial endoscopy.