Refractory peptic lesions. Therapeutic strategies for ulcers and reflux esophagitis that resist standard regimens

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.