What is the most common complication of a giant gastric ulcer: malignant transformation, perforation, upper gastrointestinal bleeding, or gastric outlet obstruction?

From the Guidelines

The most common complication of giant gastric ulcer is upper gastrointestinal bleeding (option c). Giant gastric ulcers, which are typically defined as ulcers greater than 2-3 cm in diameter, have a higher risk of complications compared to smaller ulcers due to their size and depth. Upper gastrointestinal bleeding occurs when the ulcer erodes into blood vessels in the stomach wall, particularly when it extends into the submucosa where larger vessels are located. This complication manifests as hematemesis (vomiting blood), melena (black, tarry stools), or hematochezia (bright red blood per rectum) in severe cases, often accompanied by symptoms of anemia such as fatigue and dizziness. While perforation, malignant transformation, and gastric outlet obstruction are all potential complications of giant gastric ulcers, bleeding remains the most frequently encountered complication, occurring in approximately 15-20% of cases. The extensive surface area of giant ulcers increases the likelihood of vascular erosion, making bleeding more common than the other complications listed, as supported by the WSES guidelines 1. Additionally, a recent review on the epidemiology of complicated peptic ulcer disease found that hemorrhage was by far the most common complication of peptic disease, with a reported annual incidence of hemorrhage in the general population ranging from 0.02 to 0.06% 1. Therefore, upper gastrointestinal bleeding is the most common complication of giant gastric ulcer, and its management should follow the WSES guidelines, which recommend prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment 1. Key points to consider in the management of giant gastric ulcers include:

• Prompt recognition and treatment of upper gastrointestinal bleeding
• Resuscitation when required
• Appropriate antibiotic therapy
• Timely surgical/radiological treatment
• Regular endoscopic control to monitor healing and rule out stenosis
• Consideration of local factors, such as ischemia, postoperative inflammation, stenosis, and the presence of a foreign body, in the development of early marginal ulcers 1.

From the Research

Complications of Giant Gastric Ulcer

The most common complications of giant gastric ulcer include:

• Hemorrhage: Studies have shown that giant gastric ulcers are more prone to severe hemorrhage 2.
• Perforation: Although perforation is a serious complication, it is relatively rare, occurring in less than 2% of cases 3 and approximately 7% of patients experience perforation 4.
• Penetration into contiguous organs: Giant gastric ulcers are more likely to penetrate into contiguous organs, such as the pancreas 4, 2.
• Gastric outlet obstruction: This is also a potential complication, although the exact frequency is not specified in the provided studies.
• Malignant transformation: While giant gastric ulcers are at a higher risk of malignant transformation, this is not the most common complication 5, 6, 2.

Comparison of Complications

Comparing the complications, studies suggest that:

• Severe hemorrhage is more common in giant gastric ulcers than in non-giant gastric ulcers 2.
• Penetration into contiguous organs is also more frequent in giant gastric ulcers 2.
• The risk of microscopic malignancy is higher in giant gastric ulcers than in non-giant gastric ulcers 2.

Overall, the most common complication of giant gastric ulcer is hemorrhage, as supported by studies 3, 6, 2.