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Approach to refractory or recurrent peptic ulcer disease

Section Editor
Mark Feldman, MD, MACP, AGAF, FACG
Deputy Editor
Shilpa Grover, MD, MPH, AGAF


Most peptic ulcers respond to treatment with antimicrobial therapy for Helicobacter pylori, withdrawal of nonsteroidal anti-inflammatory drugs, or treatment with potent antisecretory drugs. However, in some individuals, the ulcer is either refractory to conventional therapy or recurs following successful initial treatment. This topic will review the factors associated with refractory and recurrent peptic ulcer disease, and the evaluation and management of patients with refractory or recurrent peptic ulcer disease. The clinical manifestations, diagnosis, and initial management of peptic ulcer disease are discussed in detail, separately. (See "Peptic ulcer disease: Clinical manifestations and diagnosis" and "Peptic ulcer disease: Management".)


A peptic ulcer is an excavated defect in the gastric or duodenal mucosa that extends through the muscularis mucosa into the deeper layers of the wall.

A refractory peptic ulcer is defined as an endoscopically proven ulcer greater than 5 mm in diameter that does not heal after 8 to 12 weeks of treatment with a proton pump inhibitor.

A recurrent peptic ulcer is defined as an endoscopically proven ulcer greater than 5 mm in diameter that develops following complete ulcer healing.


In the absence of continued nonsteroidal anti-inflammatory drug (NSAID) use, acid suppression heals >90 percent of peptic ulcers. However, approximately 5 to 10 percent of ulcers are refractory to 12 weeks of antisecretory therapy with a proton pump inhibitor (PPI). Even with continued PPI use, approximately 5 to 30 percent of peptic ulcers recur within the first year based on whether H. pylori has been successfully eradicated [1,2]. Risk factors for refractory and recurrent peptic ulceration include the following (table 1 and table 2) [3-6].

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Literature review current through: Nov 2017. | This topic last updated: Jul 05, 2017.
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