Gastric ectopic pyloric opening: an unusual case
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Stomach is the most dilated part of the digestive tube. The shape of the stomach could vary frequently without any clinical symptoms. Abnormality of pylorus including double pylorus and congenital pyloric stenosis has been reported but pyloric ectopic opening has not been reported before. We found a rare case of pyloric ectopic opening in the stomach body with a “hammer” shape stomach in a 72-year-old man. The patient complained of upper left abdominal with no past medical history or surgery history. The double-contrast examination showed a “hammer” shape stomach, with the pylorus opening high at the lesser curvature and enlarged distal end of the stomach. The gastrointestinal endoscopy showed that the pyloric antrum was approximately 3 cm below the cardia with a round and poor functioning opening. No obvious abnormalities in the bulb and descending part of the duodenum were observed. A large ulcer with whitish exudate covering the base was found on the posterior wall. Histological examination of the ulcer showed broken mucosal glands with atypical hyperplasia and focal carcinogenesis. This case shows a probably congenital pyloric ectopic opening in the gastric body with a “hammer”-shaped stomach, adding a new gastric morphological variation.
KeywordsAbnormality of pylorus Gastric ectopic Pyloric ectopic
Stomach is the most dilated part of the digestive tube. The stomach occupies the epigastric, left hypochondriac and umbilical regions of the abdomen . Three types of stomach may persist clinically, which are hypersthenic, sthenic and hyposthenic types . Sthenic type with a “J” shape is the most common type in living individuals.
Shape and position of the stomach can vary greatly with or without any physiological disturbances. Burdan et al. classified the anatomical variations of the stomach in five primary groups based on the radiological and historical data, which are abnormal position along longitudinal or horizontal axis, abnormal shape, abnormal stomach connections, and mixed form . Among the variations of stomach, abnormality of pylorus is not commonly reported. One of the most commonly reported abnormalities of pylorus is congenital pyloric stenosis . Few relevant reports to our knowledge about the pyloric ectopic opening have been reported. Here, we report a rare case of pyloric ectopic opening in the stomach body.
A 72-year-old man complained of upper left abdomen discomfort for 3 weeks and aggravated for 2 days. No complaint of nausea, vomiting, abdominal pain, weight change, abdominal pain, diarrhea or other digestive disorder symptoms was reported. He was admitted to the gastroenterology department on December 21, 2015. The patient denied any past medical history or past surgery history. He had never smoked, and drunk alcohol only occasionally.
On examination, the patient was in good health. No abnormality in vital sign was detected. No other congenital abnormality was noticed during physical examination. His abdomen was non-tender, and no palpable mass was found.
The examination also showed a bilateral sign on the small curvature of the gastric mucosa, with a fixed shape, partially absent in the gastric antrum (Fig. 1b). In summary, abnormal pyloric opening in the stomach body and lesions on the lesser curvature was found.
A second gastrointestinal endoscopy was performed 2 weeks later. Under endoscopy, the gastric fundal mucosa was shown to be congested with edema. A large number of brown stomach contents were observed in the stomach. The stomach body and the gastric antrum were shortened. The gastric antrum was a cystic blind end. A large ulcer with whitish exudate covering the base was found on the posterior wall, and the border of the ulcer was not clear and poorly elastic. Around the ulcer, there is rough and brittle mucosal uplift and biopsy was done. The pyloric antrum was located at the upper lesser curvature. The pyloric open was round with poor function. No obvious abnormalities in the bulb and descending part of the duodenum were observed (Fig. 2b).
Rough histological examination of the specimen showed broken mucosal glands with atypical hyperplasia and focal carcinogenesis. Detailed histological examination and surgery were recommended but refused by the patient.
Discussion and conclusions
In this case report, a pyloric ectopic opening in the stomach body with rough histologic examination is presented.
Stomach is the most dilated part of the digestive tube. Three types of stomach may persist clinically, which are hypersthenic, sthenic and hyposthenic types . The shape of the stomach could vary frequently without any clinical symptoms. Burdan et al. classified the anatomical variations of the stomach into five primary groups, which are abnormal position along longitudinal or horizontal axis, abnormal shape, abnormal stomach connections, and mixed forms . Another study on the shape and topography of stomach anatomical classification grouped the anatomical variation of stomach as herniated, malrotated and congenital variants . Normally, pylorus opens in the distal antrum with a length of about 5 mm. Abnormality of pylorus including double pylorus and congenital pyloric stenosis has been reported [5, 13]. In this case, the pylorus was approximately just 3 cm below the cardia and had the opening high at the lesser curvature, making the stomach in a “hammer” shape, which has not been reported before.
Variations of stomach anatomy
Hypertrophic pyloric stenosis 
Elongation of the pyloric channel, indentation of both duodenal bulb and gastric antrum by the pyloric mass, and gastric hyperperistalsis that stops abruptly at the pylorus.
Double pylorus 
Fistulous communication between the gastric antrum and the duodenal bulb.
“Hourglass” stomach 
The stomach had two distinct pouches. The two pouches were formed due to the presence of an unusually deep notch at the greater curvature. Both the pouches communicated with the distal end of the esophagus.
Variation in stomach shape and pyloric opening may be with some clinical disturbance. The ectopic pylorus raised the outflow tract and may result in delayed gastric emptying. Chronically, gastroptosis and decreased gastric motility may occur and patients may complain about abdominal distention or vomit after meal. Studies have shown that Helicobacter pylori infection might delay the gastric emptying [3, 9] and the decreased gastric motility in these patients might result in complications. In Einhorn et al.’s work, double pylorus is associated with symptoms suggesting peptic ulcers, and a small part of patients reported gastric bleeding . They also showed 80% of patients responded well to medical therapy and were free of complications . For 20% of anatomical variations that cause complication, correcting for the variation may benefit the symptoms . In this case, non-ectopic pylorus-related symptoms were presented. However, it is possible that the delayed gastric emptying may worsen the HP infection and ulcer. Unfortunately, the HP test was refused by the patient.
In summary, this case showed a pyloric ectopic opening in the gastric body with a “hammer” shape stomach. This type of stomach may be unnoticed throughout patients’ life without any complication. Our case adds a new gastric morphological variation, which may be important to radiologist in the interpretation of double-contrast examination.
BL carried out the study concepts, study design, experimental studies, data acquisition, data analysis and manuscript editing; LY was dedicated to the data analysis, manuscript preparation and manuscript editing. All authors have read and approved this article.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Compliance with ethical standards
The authors declare that they have no competing interest.
- 2.Burdan F, Zinkiewicz K, Szumiło J, Różyło-Kalinowska I, Starosławska E, Krupski W, Dworzański W, Dąbrowski A, Wallner G (2012) Anatomical classification of the shape and topography of the operated stomach. Folia Morphol (Warsz) 71:129–135Google Scholar
- 4.Datta A (2006) Essentials of human anatomy (thorax and abdomen). Current Books International, ChennaiGoogle Scholar
- 6.Gray H (1901) Gray’s Anatomy, descriptive and surgical.(1974 printing edited by TP Pick and R. Howden). Running Press, PhiladelphiaGoogle Scholar
- 7.Margulis AR, Burhenne HJ (1989) Alimentary tract radiology, 4th edn. C.V. Mosby Co, St. LouisGoogle Scholar
- 9.Miyaji H, Azuma T, Ito S, Abe Y, Ono H, Suto H, Ito Y, Yamazaki Y, Kohli Y, Kuriyama M (1999) The effect of Helicobacter pylori eradication therapy on gastric antral myoelectrical activity and gastric emptying in patients with non-ulcer dyspepsia. Aliment Pharmacol Ther 13:1303–1310CrossRefGoogle Scholar
- 10.Moore KL, Dalley AF, Agur AM (2013) Clinically oriented anatomy. Lippincott Williams & Wilkins, BaltimoreGoogle Scholar
- 11.Nayak SB (2017) An atypical “hourglass” stomach due to the presence of an unusual incisure at the greater curvature. Online J Health Allied Sci 16(1):13Google Scholar
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