Abstracts
1997 Digestive Disease Week

Giant peptic ulcer: a surgical or medical disease?

D Simeone, A Hassan, J Scheiman. Departments of Surgery and Internal Medicine, University of Michigan Medical School, Ann Arbor, MI.

Medical management of giant gastric and duodenal ulcers has traditionally been associated with a significant incidence of morbidity and mortality, dictating the need for surgical intervention. Recently, increasing use of therapeutic endoscopy, potent antisecretory drugs, as well as a better understanding of peptic ulcer disease pathogenesis may have reduced the number of patients who require surgery. METHODS: We reviewed all endoscopy reports at our institution from 1/91 to 8/96 and the medical records of all patients with peptic ulcers >= 2 cm. The characteristics and outcomes of these patients, traditionally thought to all require surgical intervention, were evaluated. RESULTS: 75 patients: 34 males (45%) and 41 females (55%), with a mean age of 60.7 yrs (range 20- 91 yrs) were identified. The mean duration of clinical follow-up was 16.6 months (range 1 to 68 mo.). The ulcers were located in the stomach in 39 pts. (52%), duodenum in 31 pts. (41%), and both in 5 pts. (7%). The ulcers ranged in size from 2 - 6 cm with a mean size of 2.7 cm. Only 24 pts. (32%) had a prior history of peptic ulcer disease, 34 pts. (45%) had a history of NSAID use, while 9 pts. (12%) had an active history of alcohol abuse. None of these factors predicted the need for surgical intervention. The most common presentations were abdominal pain (40%), and GI bleeding (37%), however, 14 pts. presented with no symptoms and peptic ulcer disease was suspected only because of anemia or guiaic positive stools. 63 pts. (84%) were managed without surgery with a good outcome, documented by repeat EGD and /or resolution of symptoms. Medical management included antibiotic treatment if H. pylori positive (confirmed in 67% of pts.), stopping NSAID's, and potent acid suppression (usually with omeprazole). 7 pts. (9.3%) underwent successful endoscopic intervention to control bleeding. 2 pts. with ongoing bleeding but poor surgical candidates were treated successfully with angiographic embolization. Only 12 pts. (16%) required surgical intervention; 6 pts. due to bleeding, 2 pts. due to perforation, 1 pt. for obstruction, and 3 pts. felt to have intractable disease. Surgical procedures included vagotomy and pyloroplasty (7), vagotomy and antrectomy (4), and highly selective vagotomy (1). CONCLUSION: In this report of the largest series of patients with giant peptic ulcers, the majority of pts. (84%) can be managed without surgical treatment. Our data suggest that the improvements in medical therapy for giant ulcers obviates the need for eventual surgical intervention in most patients. Ulcer complications, rather than size, dictate the requirement for surgery.