Approach to refractory or recurrent peptic ulcer disease
- Nimish B Vakil, MD, AGAF, FACP, FACG, FASGE
Nimish B Vakil, MD, AGAF, FACP, FACG, FASGE
- Clinical Professor of Medicine
- University of Wisconsin School of Medicine and Public Health
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 12 weeks of treatment with a proton pump inhibitor (PPI).
●A recurrent peptic ulcer is defined as an endoscopically proven ulcer greater than 5 mm in diameter that develops following complete ulcer healing.
EPIDEMIOLOGY AND RISK FACTORS
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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- EPIDEMIOLOGY AND RISK FACTORS
- H. pylori infection
- Ulcer characteristics
- Inadequate inhibition of acid secretion
- Acid hypersecretory states
- Comorbid conditions
- Unusual causes of refractory ulceration
- INITIAL MANAGEMENT
- Eradicate H. pylori
- Avoid NSAIDs and tobacco
- Antisecretory therapy
- Endoscopic surveillance
- SUBSEQUENT MANAGEMENT
- Maintenance antisecretory therapy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS