Tuesday, February 10, 2015

Giant duodenal ulcers

The duodenum is the first - and shortest - section of the small intestine. During the digestive process, food passes there from the stomach and gets mixed with enzymes secreted by the pancreas. Duodenal ulcers - painful sores in the mucous membrane that lines the duodenal wall - are a fairly common complaint. The cause is usually infection by the insidious bacterium Helicobacter pylori (also responsible for stomach ulcers). And what's worse than a duodenal ulcer? A giant duodenal ulcer (GDU). 

The radiographic appearance of these big lesions was first described in 1931. Because the ulcer crater is so large, it can easily be missed on X-rays - it gets mistaken for a normal or slightly deformed duodenal cap. Today, endoscopy has essentially replaced barium contrast studies for visualization of the upper gastrointestinal tract and there is little difficulty with the diagnosis of these lesions. Giant duodenal ulcers are generally defined simply as a benign, full thickness ulcer at least 2 cm in diameter, usually involving a large portion of the duodenal bulb. While it's unclear why some patients develop standard-sized ulcers and some get the bigger, nastier variety, research suggests that daily use of nonsteroidal anti-inflammatory drugs (NSAIDs) is an important risk factor for GDUs.

The symptoms? This condition is typically quite painful. The pain will usually be located in the stomach area, sometimes radiating towards the right flank and/or towards the back. It is persistent and is not relieved by food or by antacid medications. Most patients show some degree of bleeding, either in the form of hematemesis (vomiting blood), melena (black stools) or hematochezia (passage of fresh red blood through the anus) or any combination of the above. Anemia often appears as a consequence of blood loss. Gastric outlet blockage can also occur, causing nausea and vomiting. Additionally, the inflammatory mass can produce significant constitutional symptoms such as weight loss, cachexia (muscle atrophy and weakness) and malnutrition. This constellation of symptoms can often mislead the clinician to suspect cancer.

Giant duodenal ulcers can cause ugly, potentially fatal complications - massive hemorrhage and/or intestinal perforation. Today, they are usually treated with proton pump inhibitors. Some patients require surgery, which is much less risky now than it used to be 40 or 50 years ago (in early case series, around 40% patients with a GDU did not survive a surgical intervention).

To prevent this condition, it's a good idea to avoid frequent use of NSAIDs, if possible.

Endoscopic photo of a giant duodenal ulcer in a patient taking non-steroidal anti-inflammatory drugs. This ulcer is larger than 2 cm. Image from: Newton et al. 2008

I found a cool 9-minute movie clip on YouTube, posted by DrMurraSaca, showing endoscopy of a giant duodenal ulcer. The bombastic creepy music playing in the first part of the clip is quite hilarious! Around the 5-minute mark, the soundtrack changes and we're shown a parade of endoscopy images of other conditions - gastric ulcers, hourglass stomach, ulcers with huge blood clots and the like.



Newton EB, Versland MR, Sepe TE. (2008) Giant duodenal ulcers. World J Gastroenterol. 14(32): 4995–4999.

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