Evaluation and Management: Recurrent Peptic Ulcer Disease

  • Kamran Samakar
  • Adrian B. DobrowolskyEmail author


Recurrent or refractory peptic ulcer disease has become increasingly rare as antacid therapy continues to increase and improve with time. Once regarded as a surgical disease, it has now become primarily managed medically and has etiologies ranging from viral, bacterial, comorbid conditions, medication side effects, and lifestyle choices. When traditional therapy fails and symptoms persist, repeat endoscopic evaluation in addition to identification of less common causes of recurrent or refractory peptic ulcer disease should be pursued. We have identified some of these less common and sometimes rarely studied etiologies to give the reader a full understanding of what the possibilities are worldwide. This chapter provides the reader with a framework to not only identify the often elusive etiologies but also treatment options to better assist with the management of this increasingly rare disease.


Peptic ulcer disease Refractory peptic ulcer disease Recurrent peptic ulcer disease Vagotomy Zollinger-Ellison syndrome H. pylori 


  1. 1.
    Vakil N, Grover S. Approach to refractory or recurrent peptic ulcer disease. UpToDate. 04/23/2015.Google Scholar
  2. 2.
    ASGE Standards of Practice Committee, Banerjee S, Cash BD, et al. The role of endoscopy in the management of patients with peptic ulcer disease. Gastrointest Endosc. 2010;71(4):663–8.CrossRefGoogle Scholar
  3. 3.
    Whiting JL, Sigurdsson A, Rowlands DC, Hallissey MT, Fielding JW. The long term results of endoscopic surveillance of premalignant gastric lesions. Gut. 2002;50(3):378–81.CrossRefGoogle Scholar
  4. 4.
    Hosokawa O, Watanabe K, Hatorri M, Douden K, Hayashi H, Kaizaki Y. Detection of gastric cancer by repeat endoscopy within a short time after negative examination. Endoscopy. 2001;33(4):301–5.CrossRefGoogle Scholar
  5. 5.
    Vakil N, Grover S. Peptic ulcer disease: management. UpToDate. 07/23/2015.Google Scholar
  6. 6.
    Liang XY, Gao Q, Gong NP, Tang LP, Wang PL, Tao XH. Comparison of esomeprazole enteric-coated capsules vs esomeprazole magnesium in the treatment of active duodenal ulcer: a randomized, double-blind, controlled study. World J Gastroenterol. 2008;14(12):1941–5.CrossRefGoogle Scholar
  7. 7.
    Lanza F, Goff J, Scowcroft C, Jennings D, Greski-Rose P. Double-blind comparison of lansoprazole, ranitidine, and placebo in the treatment of acute duodenal ulcer. Lansoprazole study group. Am J Gastroenterol. 1994;89(8):1191–200.PubMedGoogle Scholar
  8. 8.
    Laine L, Hopkins RJ, Girardi LS. Has the impact of helicobacter pylori therapy on ulcer recurrence in the United States been overstated? A meta-analysis of rigorously designed trials. Am J Gastroenterol. 1998;93(9):1409–15.PubMedGoogle Scholar
  9. 9.
    Malfertheiner P, Megraud F, O’Morain CA, et al. Management of helicobacter pylori infection – the Maastricht IV/Florence consensus report. Gut. 2012;61(5):646–64.CrossRefGoogle Scholar
  10. 10.
    Lanas A, Remacha B, Sainz R, Hirschowitz BI. Study of outcome after targeted intervention for peptic ulcer resistant to acid suppression therapy. Am J Gastroenterol. 2000;95(2):513–9.CrossRefGoogle Scholar
  11. 11.
    Yeomans ND, Tulassay Z, Juhasz L, et al. A comparison of omeprazole with ranitidine for ulcers associated with nonsteroidal antiinflammatory drugs. Acid suppression trial: ranitidine versus omeprazole for NSAID-associated ulcer treatment (ASTRONAUT) study group. N Engl J Med. 1998;338(11):719–26.CrossRefGoogle Scholar
  12. 12.
    Kim HU. Diagnostic and treatment approaches for refractory peptic ulcers. Clin Endosc. 2015;48(4):285–90.CrossRefGoogle Scholar
  13. 13.
    Nieto JM, Pisegna JR. The role of proton pump inhibitors in the treatment of zollinger-ellison syndrome. Expert Opin Pharmacother. 2006;7(2):169–75.CrossRefGoogle Scholar
  14. 14.
    Berna MJ, Hoffmann KM, Long SH, Serrano J, Gibril F, Jensen RT. Serum gastrin in zollinger-ellison syndrome: II. prospective study of gastrin provocative testing in 293 patients from the national institutes of health and comparison with 537 cases from the literature. evaluation of diagnostic criteria, proposal of new criteria, and correlations with clinical and tumoral features. Medicine (Baltimore). 2006;85(6):331–64.CrossRefGoogle Scholar
  15. 15.
    Dall M, Schaffalitzky de Muckadell OB, Lassen AT, Hansen JM, Hallas J. An association between selective serotonin reuptake inhibitor use and serious upper gastrointestinal bleeding. Clin Gastroenterol Hepatol. 2009;7(12):1314–21.CrossRefGoogle Scholar
  16. 16.
    Shike M, Gillin JS, Kemeny N, Daly JM, Kurtz RC. Severe gastroduodenal ulcerations complicating hepatic artery infusion chemotherapy for metastatic colon cancer. Am J Gastroenterol. 1986;81(3):176–9.PubMedGoogle Scholar
  17. 17.
    Smith AD, Bai D, Marroquin CE, et al. Gastrointestinal hemorrhage due to complicated gastroduodenal ulcer disease in liver transplant patients taking sirolimus. Clin Transpl. 2005;19(2):250–4.CrossRefGoogle Scholar
  18. 18.
    Verhamme K, Mosis G, Dieleman J, Stricker B, Sturkenboom M. Spironolactone and risk of upper gastrointestinal events: population based case-control study. BMJ. 2006;333(7563):330.CrossRefGoogle Scholar
  19. 19.
    Kim JH, Moon JS, Jee SR, et al. Guidelines of treatment for peptic ulcer disease in special conditions. Korean J Gastroenterol. 2009;54(5):318–27.CrossRefGoogle Scholar
  20. 20.
    Fireman Z, Sternberg A, Yarchovsky Y, et al. Multiple antral ulcers in gastric sarcoid. J Clin Gastroenterol. 1997;24(2):97–9.CrossRefGoogle Scholar
  21. 21.
    Diaz L, Hernandez-Oquet RE, Deshpande AR, Moshiree B. Upper gastrointestinal involvement in crohn disease: histopathologic and endoscopic findings. South Med J. 2015;108(11):695–700.CrossRefGoogle Scholar
  22. 22.
    Lohr JM, Nelson JA, Oldstone MB. Is herpes simplex virus associated with peptic ulcer disease? J Virol. 1990;64(5):2168–74.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Hori K, Fukuda Y, Tomita T, Kosaka T, Noda S. Cytomegalovirus-associated gastritis. Gastrointest Endosc. 2004;59(6):692–3.CrossRefGoogle Scholar
  24. 24.
    Jo J, Kim H, Heo S. A case of gastric syphilis diagnosed by PCR test: a case report. J Med Life Sci. 2014;11:43–7.Google Scholar
  25. 25.
    Sachdeva AK, Zaren HA, Sigel B. Surgical treatment of peptic ulcer disease. Med Clin North Am. 1991;75(4):999–1012.CrossRefGoogle Scholar
  26. 26.
    Towfigh S, Chandler C, Hines OJ, McFadden DW. Outcomes from peptic ulcer surgery have not benefited from advances in medical therapy. Am Surg. 2002;68(4):385–9.PubMedGoogle Scholar
  27. 27.
    Jamieson GG. Current status of indications for surgery in peptic ulcer disease. World J Surg. 2000;24(3):256–8.CrossRefGoogle Scholar
  28. 28.
    Vernon A, Ferzoco S, Ashley S, Chen W. Surgical management of peptic ulcer disease. UpToDate. 08/24/2015.Google Scholar
  29. 29.
    Lightner A, Brunicardi C. In: Cameron J, Cameron A, editors. The management of benign gastric ulcers. 12th ed. Philadelphia: Elsevier; 2017. p. 79–82.Google Scholar
  30. 30.
    Katkhouda N, Heimbucher J, Mouiel J. Laparoscopic posterior vagotomy and anterior seromyotomy. Endosc Surg Allied Technol. 1994;2(2):95–9.PubMedGoogle Scholar
  31. 31.
    Croce E, Azzola M, Golia M, et al. Laparoscopic posterior truncal vagotomy and anterior proximal gastric vagotomy. Endosc Surg Allied Technol. 1994;2(2):113–6.PubMedGoogle Scholar
  32. 32.
    Cadiere GB, Himpens J, Bruyns J. Laparoscopic proximal gastric vagotomy. Endosc Surg Allied Technol. 1994;2(2):105–8.PubMedGoogle Scholar
  33. 33.
    Katkhouda N. Advanced laparoscopic surgery: techniques and tips. In: second ed. New York: Springer; 2010.CrossRefGoogle Scholar
  34. 34.
    Dallemagne B, Weerts JM, Jehaes C, Markiewicz S, Lombard R. Laparoscopic highly selective vagotomy. Br J Surg. 1994;81(4):554–6.CrossRefGoogle Scholar
  35. 35.
    Zittel TT, Jehle EC, Becker HD. Surgical management of peptic ulcer disease today--indication, technique and outcome. Langenbeck’s Arch Surg. 2000;385(2):84–96.CrossRefGoogle Scholar
  36. 36.
    Taylor TV, Lythgoe JP, McFarland JB, Gilmore IT, Thomas PE, Ferguson GH. Anterior lesser curve seromyotomy and posterior truncal vagotomy versus truncal vagotomy and pyloroplasty in the treatment of chronic duodenal ulcer. Br J Surg. 1990;77(9):1007–9.CrossRefGoogle Scholar
  37. 37.
    Petrakis I, Vassilakis SJ, Chalkiadakis G. Anterior lesser curve seromyotomy using a stapling device and posterior truncal vagotomy for the treatment of chronic duodenal ulcer: Longterm results. J Am Coll Surg. 1999;188(6):623–8.CrossRefGoogle Scholar
  38. 38.
    Croce E, Olmi S, Russo R, Azzola M, Mastropasqua E, Golia M. Laparoscopic treatment of peptic ulcers. A review after 6 years experience with hill-barker’s procedure. Hepato-Gastroenterology. 1999;46(26):924–9.PubMedGoogle Scholar

Copyright information

© SAGES 2019

Authors and Affiliations

  1. 1.Department of Upper GI, General, and Bariatric SurgeryUSC Keck Medical CenterLos AngelesUSA

Personalised recommendations