Site and localization of duodenal ulcers: a study at operation.

At operations on 150 patients the duodenal bulb was examined for local features which predispose it to peptic ulceration. A surgeon now has the opportunity to study the duodenum in its natural state and normal situation in both healthy and ulcerated conditions. When gastroenterostomy or partial gastrectomy were routinely used for the cure of duodenal ulcers, the bulb was either left unopened or destroyed. The use of Heineke-Mikulicz pyloroplasty or mucosal antrectomy (Kirk, 1965, 1966) in the treatment of peptic ulcers allows careful internal inspection of the duodenal bulb. Postmortem studies (Hurst and Stewart, 1929; Portis and Jaffe, 1938) have shown that duodenal ulcers are usually single, near the pylorus, either on the anterior or posterior wall of the bulb. The ulcers are discrete; Doniach and Shiner (1957) did not detect any significant difference between duodenal mucosal biopsy specimens removed from normal and duodenal ulcer subjects. If an excess of hydrochloric acid were the only cause of duodenal ulcers, the whole bulbar chamber, which receives and temporarily retains gastric chyme, should be excoriated, or ulcers should be situated fortuitouisly. Intensive research has been concentrated on the effects of gastric hypersecretion in the production of duodenal ulcers. In contrast, study of the factors which determine the site and discreteness of the ulcers has been neglected. The theories which have been put forward to explain the site and localization of duodenal ulcers is reviewed below.