Despite the fact that treatment with twice daily proton pump
inhibitors (PPIs) will result in healing of all benign ulcers, there are still
a minority of patients who have ulcers refractory to treatment.
Before considering the presence of an underlying pathology other
than benign peptic ulcer disease, patient compliance with therapy should be
ensured, as non-compliance is the most common cause.
Next to treatment non-compliance, are the use of aspirin and
Non-steroidal anti-inflammatory drugs (NSAIDs), and the presence of H Pylori
infection.
Other causes that must be suspected based on the clinical data:
Gastric adenocarcinoma
Gastric lymphoma
Zollinger-Ellison syndrome
Cameron ulcers (linear ulcers in large hiatus hernias)
Treatment with bisphosphonate
Crohn's disease
Infections: Cytomegalovirus (CMV), and mucormycosis
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