Giant duodenal ulcer (GDU) is a variant of peptic ulcer disease and is defined as a duodenal ulcer crater that is benign and at least 2 cm in diameter. This subset of duodenal ulcers have historically resulted in greater morbidity than usual duodenal ulcers since, by definition, they involve the full thickness of the duodenal wall and occupy a significant portion of the duodenal bulb. Brdiczka first called attention to this entity in 1931 and emphasized the difficulty in diagnosing them with barium roentgenogram. Although once thought to be a rare variant, with the advent of flexible endoscopy and awareness of this entity numerous case reports and case series have been published in the literature. GDUs comprise approximately 1% to 2% of all duodenal ulcers and 5% of peptic ulcers requiring surgical intervention. In the initial reports, few patients were successfully treated with medical therapy. Surgery was favored as the treatment of choice for this disease, and high mortality rates were reported despite surgical intervention. Improvements in surgical techniques have revolutionized the operative treatment and outcome of this condition. However, today, with the widespread use of endoscopy, the introduction of histamine-2 receptor antagonists and later proton pump inhibitors (PPIs), medical treatment has replaced operation as the first line of treatment for the patient with GDU. Because of the large, penetrating nature of these ulcers, when not recognized and treated promptly, complications such as hemorrhage and perforation remain common, and GDUs are still associated with high rates of morbidity and mortality. Thus, surgical evaluation of a patient with GDU should remain an integral part of patient care in all cases. There are important differences when comparing GDUs to classic peptic ulcers, and they must be approached differently than their more common counterpart.

Standard-sized ulcer disease affects males greater than females at a rate of approximately 2 to 1, whereas it is 3 to 1 for GDU. The etiology of standard-sized and GDUs has been associated with two major contributing causes: recent usage of nonsteroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori infection. However, the percentage of GDUs caused by H. pylori is less when compared to standard-sized ulcers, and NSAID use plays a more prominent role.

The most common presenting symptom is abdominal pain. Most patients describe the pain as involving the epigastric region, and some experience involvement of the right hypochondrium and/or radiation into the back, particularly when the ulcer penetrates into the pancreas. The pain is more intense and persistent than the pain found with usual ulcer patients. The pain is generally not relieved with food or antacids and weight loss is a frequent comorbidity.