Giant gastric ulcer: Its natural history and outcome in the H2RA era

OBJECTIVE: The aim of this paper is to study the natural history and outcom e of medical treatment of giant gastric ulcer in the histamine H2-receptor antagonist era. METHODS: All patients with gastric ulcer were prospectively followed. We as sessed the special features (in particular, demography and treatment outcom e) in patients with giant gastric ulcer, defined as ulcers large enough to occupy at least one wall. RESULTS: Between 1976 and 1991, 537 patients with gastric ulcer were seen, of whom 129 (24%) had giant gastric ulcer. Giant gastric ulcer patients wer e significantly older (p < 0.05) than patients with smaller ulcers and had more aggressive disease, reflected by a higher incidence of bleeding, anore xia, weight loss, and emergency admission. More giant gastric ulcers were l ocated in the body of the stomach and a higher proportion looked malignant. Four of 129 patients died immediately (bleed n = 3, unrelated cause n = 1) , 15 had urgent: surgery (bleed n = 11, perforation n = 2, suspected cancer n = 2) and 110 were treated medically, mainly with cimetidine 1 g daily. H ealing occurred in 97 of 110 (88%), including 14 of 15 with refractory dise ase, i.e., healing took >3 months and/or needed cimetidine 2-3 g daily. Of the remaining 13 patients, six died (from unrelated causes), three had surg ery for failed medical treatment, two defaulted, and two were still on trea tment (one with refractory ulcer). Refractoriness was more common in patien ts with associated major medical illness (42% vs 12%, p < 0.01) or with gia nt gastric ulcers that looked malignant although they were benign (53% vs 2 1%, p < 0.01). Relapse off treatment was higher (13 of 26) than on maintena nce treatment with cimetidine 0.4-2 g daily (14 of 70). Complications occur red in six patients: four off treatment and two on maintenance treatment. O nly two giant gastric ulcers finally proved to be malignant. Of the 129 pat ients, 47 (36%) died, 14 within 3 months (two from bleeding, three postoper atively, nine from unrelated causes) and 33 later (two with gastric cancer and 31 from unrelated causes). CONCLUSIONS: Giant gastric ulcer is uncommon. Patients are more seriously i ll than those with smaller ulcers. Most giant gastric ulcers heal with hist amine H2-receptor antagonist treatment. The condition is a marker of poor g eneral health, reflected by the high long term mortality. (Am J Gastroenter ol 1999;94:3478-3486, (C) 1999 by Am. Coll. of Gastroenterology).