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Am Fam Physician. 2000;61(5):1473-1474

A giant duodenal ulcer is a full-thickness peptic ulcer that is 2 cm or larger in diameter. Management of this sort of ulcer has typically been surgical because of the high risk of bleeding, perforation and obstruction. Truncal vagotomy to reduce gastric acid production is the preferred surgical management approach. A few small studies have supported medical management of such ulcers, but study participants were treated only with antacids and cimetidine. This latter class of medications was shown in another study to be useful for short-term management of giant duodenal ulcers but not for preventing recurrences. Fischer and colleagues performed a prospective study to determine the efficacy of omeprazole, a proton-pump inhibitor (PPI), in the treatment of large duodenal ulcers.

Eligible patients were at least 21 years of age and were found by endoscopy to have a duodenal ulcer that was 2 cm or greater in diameter. Exclusion criteria included pregnancy, a pyloric channel ulcer, gastric cancer, gastrinoma or coexistent cardiac or pulmonary conditions that were severe enough to preclude elective surgery. At the time of endoscopy, most patients underwent antral biopsy to test for Helicobacter pylori. A fasting serum gastrin level was obtained, and an H. pylori enzyme-linked immunosorbent assay was performed. Eligible patients were given 40 mg of omeprazole daily and were then seen for follow-up evaluations at six weeks, 12 weeks and one year. Endoscopy was performed at each visit. Ongoing medical evaluations were completed for an additional 12 months. If the ulcer was not healed by the 12-week visit, omeprazole therapy was continued and, if the patient tested positive for H. pylori, treatment for this infection was added. If the ulcer was noted to be less than 1 cm in size and the H. pylori test was negative, the omeprazole therapy was continued for three-month intervals until ulcer healing was documented by endoscopy. These patients were maintained on 150 mg of ranitidine at bedtime for an additional 12 months. If at any time during the medical treatment bleeding, perforation or obstruction developed, a gastroenterologist, in consultation with the surgeon, decided if surgery was indicated.

The 28 patients enrolled in the study had a mean age of 59 ± 2.2 years. Approximately 71 percent of the patients were male, and 86 percent were white. Thirty-nine percent of the patients had a history of nonsteroidal anti-inflammatory drug use, and 25 percent had a history of alcohol abuse. Twenty-four patients initially presented with signs or symptoms of gastrointestinal hemorrhage. Only nine patients tested positive for H. pylori. Of the patients who underwent primary medical management, one had early surgery for uncontrolled bleeding. Of the remaining 27 patients, only seven required surgical intervention because of complications of giant duodenal ulcer or failure of medical therapy. Six of these patients had an adherent blood clot on the ulcer at initial endoscopy. Of the seven required surgeries, four were required because of rebleeding and three because of gastric outlet obstruction. Fifteen of the 20 patients who did not require surgery had complete ulcer healing, including 12 within the first six weeks of therapy. The remaining five patients had varying degrees of follow-up and medical therapy until completion of the study.

The authors conclude that omeprazole is effective in the treatment of giant duodenal ulcers. In most cases, successful treatment can be accomplished in six weeks. Patients who have adherent clot on their ulcer at endoscopy are at increased risk of rebleeding, as was the case in six of seven patients in this series. The authors observed that only 39 percent of patients with duodenal ulcers were infected with H. pylori. This percentage is considerably lower than the 90 percent or greater incidence of infection in patients with peptic ulcer disease reported in the literature.

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