In some patients, peptic lesions fail to heal after 2 to 3 months of standard histamine2 (H2) receptor antagonist or
sucralfate (
Carafate)
therapy. Noncompliance with prescribed treatment, cigarette smoking, gastric acid hypersecretory states (including
Zollinger-Ellison syndrome), Helicobacter pylori
infection, the use of nonsteroidal anti-inflammatory drugs, abdominal
radiation therapy, and malignant
tumors are all causes of refractory disease. Treatment options include high-dose H2 receptor antagonist
therapy or switching to a more potent
drug or one with a different mechanism of action. Occasionally,
drug combinations (eg, H2 receptor antagonist plus
misoprostol [
Cytotec] for
gastric ulcers or H2 receptor antagonist plus
metoclopramide [Octamide,
Reglan] for reflux disease) are effective. Triple-
drug therapy for H pylori
infection with refractory
duodenal ulcers may allow healing and dramatically decrease recurrence rates. When surgery is required,
vagotomy and antrectomy is probably the procedure of choice in patients with
peptic ulcer disease that is refractory to medical management. Nissen
fundoplication is effective in patients with
reflux esophagitis who have adequate esophageal motility.