Persisting H. pylori infection |
Poor compliance with treatment |
Resistant organism |
Inadequate H. pylori regimen |
Unrecognized H. pylori infection: |
False negative H. pylori testing |
Skipped or inadequate testing |
Ulcers related to nonsteroidal anti-inflammatory drugs (NSAIDs) |
Continued NSAID use |
Undiscovered NSAID use |
Poor response to co-therapy with a proton pump inhibitor (PPI) or histamine 2 receptor antagonist (H2RA) |
Other mechanisms |
Impaired healing: |
Cigarette smoking |
Inadequate inhibition of acid secretion: |
Poor compliance with treatment |
Pharmacologic resistance or tolerance to H2RAs |
Pharmacologic resistance to PPIs |
Rapid metabolism (inactivation) of PPIs |
Hypersecretory states: |
Gastrinoma |
Antral G cell hyperfunction |
Idiopathic hypersecretory duodenal ulcer |
Co-therapies: |
Glucocorticoids (especially when given with NSAIDs) |
Cytotoxic drugs |
Other drugs, such as methamphetamine or cocaine use |
Uncommon causes: |
Cancer |
Crohn disease |
Infections other than H. pylori |
Eosinophilic, inflammatory, infiltrative conditions, mesenteric ischemia |