Postbulbar peptic ulceration of the duodenum.

One hundred and twenty patients operated upon for peptic ulcer diathesis had intraluminal digital examination of the duodenum seeking post-bulbar ulcers. Twelve such ulcers were found, an incidence of 10 per cent. In six of these patients, the postbulbar ulcer was an unexpected finding, and in two patients, a second ulcer was present. A review of the patients with postbulbar ulcers revealed that these patients had severe ulcer symptoms that responded poorly to medical management. Our patients were treated by truncal vagotomy and an outlet procedure. In ten patients, the anterior duodenotomy was extended to include the stenotic area. A Jaboulay gastroduodenostomy was performed in one patient, and duodenoplasty with pyloroplasty in another patient. These 12 patients were observed from one to six years. There were no deaths. Two patients had temporary gastric atony and one patient had a dumping syndrome. Three patients have had possible recurrence of the ulcer, reoperation being required in one patient. It is possible that unrecognized postbulbar stenosis may be a cause of recurrent peptic ulcer following some surgical procedures. To recognize these ulcers, we believe that the duodenum should be inspected by intraluminal palpation in all patients operated upon for peptic ulcer disease.