GIANT MARGINAL ULCER

Marginal ulcer is a well-known complication of gastroenterostomy. It occurs in 3% of patients post-Billroth II subtotal gastrectomy; it occurs in less than 1% if truncal vagotomy is included but in up to 30% of patients with gastroenterostomy without vagotomy [10, 11, 14, 16]. These ulcers occur at the anastomosis, but always on the jejunal side, and are known to develop complications of their own - e.g., intractable pain, hemorrhage, obstruction, perforation, and fistula formation [6, 8, 17]. Prior to the advent of upper-GI endoscopy the main method of diagnosis was by history and upper GI series but the accuracy of the upper-GI series was about 50% or less. Now that upper-GI endoscopy is available, the accuracy of diagnosis is 95% or better. Since truncal vagotomy has been widely adopted as an integral part of gastric surgery - e.g., antrectomy, hemigastrectomy, subtotal gastrectomy, and gastroenterostomy - the incidence of marginal ulcer has declined. The use of cimetidine, ranitidine, famotidine, omeprazole, sucralfate, and antacids has improved the medical management of duodenal ulcer to such a degree that in recent years there is much less need for surgical intervention and thus the incidence of marginal ulcer has declined even more. In addition, the H-2 blockers and omeprazole can be used in patients with marginal ulcer and achieve healing; therefore complications that so frequently required surgical intervention are much less frequent [3, 12]. This report describes the clinical course of a patient with a virulent form of marginal ulcer and recurrent gastric bezoars, who was 5 years post truncal vagotomy and hemigastrectomy, with no evidence of a Zollinger-Ellison syndrome and low gastric acid as determined by two studies.