Metastatic pancreatic cancer presenting as a bleeding duodenal ulcer 30 months after initial diagnosis of duodenal ulcer. Should duodenal ulcers be biopsied or followed up with repeat endoscopy ?

Management of duodenal ulcer (DU) includes correc- tion of underlying cause and a course of proton pump inhibitors for ulcer healing. In patients with Helicobacter pylori related DU, H pylori should be eradicated. In patients with non-steroidal anti-inflammatory drugs (NSAIDS), NSAIDS should be stopped or switched to a COX-2 inhibitor if possible (1). Unlike gastric ulcer, most management guidelines do not recommend routine biopsy of the ulcer edge to exclude, nor follow-up endoscopy to document healing (1-2). We report a patient who presented with a duodenal bulb ulcer associated with H. pylori, who was treated but defaulted follow-up and subsequently presented with an ulcer at the same location, which turned out to be malignant. A 46 years old male smoker was referred to our department for 2 days of epigastric pain.