Version June 2024
| 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 |
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