Diagnostic Problems in Cases of Large or Giant Duodenal Ulcer

Abstract

The roentgen diagnosis of gastro-intestinallesions has advanced steadily since Cannon, in 1898, first made use of the opaque meal. Wider and more extensive use of x-rays with resultant wider experience, diffusion of information through the literature, and improvements in equipment have led to diagnostic refinements. Whereas mistakes were formerly due in large part to faulty technic, they are now chiefly attributable to errors in interpretation, provided the examinations and films are made in well equipped laboratories. Hypersthenic, obese, and very ill patients, however, still present difficult technical problems. The object of this communication is to point out one of the diagnostic pitfalls that may be avoided, if we know of the existence of giant ulcers and are alert to their appearance. Errors of interpretation are not uncommon, especially in the diagnosis of gastro-intestinallesions, but these cases do not always find their way into print. It is a common experience for the gastro-intestinal surgeon and the pathologist to be asked by the general practitioner as to the benignity or malignancy of a lesion and to have to reply that it is impossible to say from inspection and palpation alone, that opinion must be reserved until microscopic sections are available. The roentgen findings are likewise morphologic rather than microscopic. This is not an adverse criticism. It is a well known fact that a final decision must often be reserved. A working hypothesis is, however, necessary and here experience and clinical judgment enter. In the case to be recorded the error was due to lack of experience with the type of lesion eventually discovered. The case is of interest because of the paradoxical findings, because of their rarity, and because of the size of the pathological specimen. Duodenal ulcers vary for the most part between 4 mm, and 10 mm. in diameter. It is unusual to find one exceeding a centimeter, and only rarely are giant ulcers encountered measuring between 2 and 4 cm. and involving the entire duodenal bulb. These must, however, be somewhat more common than the reported cases would indicate. Only 9 examples have been reported in the roentgen literature up to the present time and but two of these appear in the American literature. Brdiczka (1), in 1931, reported the first three cases and Knutsson (2), in 1934, added 4 more. Two additional examples were reported by Freedman and Goehring (3), in 1940. As the above authors have emphasized, these huge ulcers are easily overlooked, although one would expect that they would be most easily diagnosed. Their demonstration is of even more importance than the demonstration of a smaller ulcer. Roentgenographically these giant ulcers closely simulate a normal or slightly abnormal cap and according to E. Freedman the niche may suggest a duodenal diverticulum. The diagnosis in Brdiczka's first 2 cases was missed; in the third patient the experience gained from the 2 earlier cases made possible a correct diagnosis.