What is an intractable duodenal ulcer and how should it be managed?

An intractable duodenal ulcer is an ulcer that has not healed after 8 weeks of full-dose treatment with a modern anti-ulcer drug. Such ulcers are relatively rare--perhaps five in 100 patients will have intractable duodenal ulceration. The differential diagnosis includes non-compliance as a cause of continuing ulceration, hypersecretion of gastric acid or other rare causes of ulcers in the duodenum. Investigations should include biopsy of the continuing ulceration at endoscopy, measurement of fasting plasma gastrin and routine haematology and biochemistry profiles. An intractable duodenal ulcer can be treated either by using a powerful antisecretory regimen (high doses of ranitidine or famotidine or a conventional dose of omeprazole), by changing to tripotassium dicitrato bismuthate or, in exceptional circumstances, by extremely careful surgical intervention.