Management of giant duodenal ulcer

Giant duodenal ulcer is a variant of peptic ulcer that is 2 cm in diameter or greater and essentially replaces the duodenal bulb. Diagnosis by upper gastrointestinal series is often missed, due to the large size of the ulcer, which causes it to look like a scarred duodenal bulb or duodenal diverticulum. This study reviews our experience with 32 patients who presented with giant duodenal ulcer between 1963 and 1982. Seventy-five percent of the patients were men between 30 and 81 years of age (mean age 59 years). Gastrointestinal hemorrhage was a presenting symptom in 75 percent of the patients and free perforation in 9 percent. Diagnosis was made by upper gastrointestinal series (24 patients), and endoscopy (11 patients), alone or in combination. Three patients were diagnosed at surgery and one at necropsy. Mean size of the ulcer was 3.5 cm in diameter, range 2 to 6 cm. Twenty-four patients were initially managed medically (mean length of treatment 41 months), with 2 deaths (hemorrhage) and 20 recurrences (83 percent). Twenty-seven operations were required in 25 patients. In 17 of the 25, medical treatment had failed. Seven of these patients required emergency surgery. Eight patients were managed primarily by surgery, of whom five presented emergently. There were three deaths in the surgical group after emergency surgery. In two of these patients, medical treatment had failed. There were no deaths among the elective surgery group. Twenty-five of the 27 operative procedures were definitive, acid-reducing operations (15 vagotomy and antrectomy and 10 vagotomy and drainage). Two patients underwent emergency exploration and oversewing of a giant perforated ulcer alone, and both patients required subsequent surgery because of symptoms. The results indicate that giant duodenal ulcer should be primarily surgically managed and that an acid-reducing procedure should be performed during primary surgery. These patients do very poorly with medical therapy, and the mortality rate is increased if emergency surgery is required for hemorrhage. Medical treatment alone is associated with a high morbidity (92 percent). Should operation be required, a definitive acid reduction operation is the procedure of choice.