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Am Fam Physician. 2000;61(4):1123

Gastric and duodenal ulcers larger than 2 cm carry an increased risk of complications such as bleeding, obstruction and perforation. While surgical intervention is generally advocated for large ulcers, this recommendation precedes the availability of histamine H2 receptor antagonists and the recognition of the pathogenic role of Helicobacter pylori. Simeone and colleagues performed a retrospective review of upper gastrointestinal endoscopy reports at their hospital to determine if the use of endoscopic and medical therapy has reduced the need for surgery in patients with large peptic ulcers.

The retrospective chart review uncovered 75 cases of giant (2 cm or greater) benign peptic ulcers among the 15,000-plus upper gastrointestinal endoscopic examinations performed from January 1991 to August 1996. Giant ulcers were noted in 41 women and 34 men whose mean age was 60.7 years. The ulcers were in the stomach in 39 patients (52 percent), in the duodenum in 31 patients (41 percent) and in the stomach and duodenum in five patients (7 percent). The mean size of the ulcers was 2.9 cm. The mean duration of follow-up was 36 months. Of interest, 45 percent of the patients had a history of daily use of nonsteroidal anti-inflammatory drugs during the month before the diagnosis of ulcer, and 12 percent had a history of alcohol abuse.

In 63 (84 percent) of the 75 patients, the ulcers were treated medically. The remaining 12 patients required surgery. Reasons for surgical intervention included hemorrhagic shock, blood loss greater than six units of packed red blood cells, perforation, gastric outlet obstruction and persistence of ulcer despite three months of drug therapy.

The most common symptoms in the patients treated medically were abdominal pain (40 percent of the patients) and gastrointestinal bleeding (38 percent of the patients). The ulcers were asymptomatic in 22 percent of patients, but the diagnosis was suspected because of anemia or hemepositive stool. Laboratory testing for H. pylori infection was conducted in 50 of the 75 patients. The results were positive in 39 (78 percent) of these 50 patients.

Medical treatment included an antibiotic and an acid suppressive agent (an H2 antagonist or a proton pump inhibitor), as well as cessation of nonsteroidal anti-inflammatory drug use. In the majority of patients, medical therapy was successful as documented by follow-up endoscopy two to three months after the diagnosis. When follow-up endoscopy was not performed, the ulcers were deemed “cured” on the basis of resolution of symptoms and eradication of H. pylori. Nine of the medically treated patients required endoscopic intervention to control bleeding. There were no deaths in either of the treatment groups.

The authors state that their study represents the largest reported series of cases of giant peptic ulcers and provides evidence that medical therapy is appropriate. They point out that studies to support the recommendation of surgical intervention as the preferred treatment were done before the availability of H2 blockers and proton pump inhibitors and before the recognition of the role of H. pylori in the pathogenesis of peptic ulcer.

While patients found to have gastric cancer on initial endoscopy were excluded from the analysis, the authors note that cancer was not diagnosed in any of the medically treated patients during follow-up. In view of their findings, the authors believe that ulcer complications, not size, should determine the need for surgical intervention.

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