Nussbaum M S, Schusterman M A
Am J Surg. 1985 Mar;149(3):357-61. doi: 10.1016/s0002-9610(85)80107-0.
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.
巨大十二指肠溃疡是消化性溃疡的一种变体，直径达2厘米或更大，基本上占据了十二指肠球部。由于溃疡尺寸较大，上消化道造影常漏诊，因为它看起来像瘢痕化的十二指肠球部或十二指肠憩室。本研究回顾了1963年至1982年间32例巨大十二指肠溃疡患者的治疗经验。75%的患者为30至81岁的男性（平均年龄59岁）。75%的患者以胃肠道出血为首发症状，9%的患者出现游离穿孔。诊断通过上消化道造影（24例患者）、内镜检查（11例患者）单独或联合进行。3例患者在手术时确诊，1例在尸检时确诊。溃疡平均直径为3.5厘米，范围为2至6厘米。24例患者最初接受内科治疗（平均治疗时长41个月），2例死亡（出血），20例复发（83%）。25例患者需要进行27次手术。25例患者中有17例内科治疗失败。其中7例患者需要急诊手术。8例患者主要接受手术治疗，其中5例为急诊手术。急诊手术后手术组有3例死亡。其中2例患者内科治疗失败。择期手术组无死亡病例。27例手术中有25例为确定性的胃酸分泌减少手术（15例迷走神经切断术加胃窦切除术和10例迷走神经切断术加引流术）。2例患者仅接受了巨大穿孔性溃疡的急诊探查和缝合术，且这2例患者随后均因症状需要再次手术。结果表明，巨大十二指肠溃疡应主要采取手术治疗，且初次手术时应进行胃酸分泌减少手术。这些患者内科治疗效果很差，若因出血需要急诊手术，死亡率会升高。单纯内科治疗发病率很高（92%）。若需要手术，确定性的胃酸分泌减少手术是首选术式。
