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Important points:

1. Endoscopy is becoming the first-line diagnostic study (upper GI barium study is classically done first) and is more sensitive (but more expensive) than x-ray.

2. Always biopsy any gastric ulcer to exclude malignancy (duodenal ulcers do not have to be biopsied initially).

3. The major complication is perforation. Look for peritoneal signs, history of peptic ulcer disease, or free-air on abdominal x-ray. Treat with antibiotics and laparotomy with repair of perforation:

s If ulcers are severe, atypical, or nonhealing, think about Zollinger-Ellison syndrome (get gastrin, level) or stomach cancer. «i Diet changes m no! thought to help heal ulcers (but reduced alcohol or tobacco use may help).

¡a Start treatment with antacids, H2 blockers or proton-pump inhibitors, as well as antibiotics to eliminate H. pylori. Triple therapy (ampicillin or amoxicillin, metronidazole, and bismuth) is the gold standard, but many regimens are in use.

4. Surgical options should be considered after failure of medical treatment or in patients with complications (perforation, bleeding). Common procedures include antrectomy, vagotomy, and Billroth I and II. After surgery (especially Billroth procedures) watch for dumping syndrome (weakness, dizziness, sweating, nausea or vomiting after eating). Patients also may develop hypoglycemia 2-3 lir after the meal, which causes the same symptoms to recur; afferent loop syndrome (bilious vomiting after a meal relieves abdominal pain), bacterial overgrowth, and vitamin deficiencies (Bu arid/or iron, causing anemia).

5. Achlorhydria, the absence of hydrogen chloride, is associated with pernicious anemia (antiparieta! cell antibodies destroy parietal cells and thus cause achlorhydria and B12 deficiency).

Upper versus lower gastrointestinal bleeding (see table, top of next page).

Important points;

1. The first step is to make sure that the patient is stable (ABCs, IV fluids and blood if needed); then get a diagnosis.

2. Endoscopy is usually the first lest performed (upper or lower, depending oil symptoms). Classically, barium x-ray studies were performed first, but endoscopy is more sensitive.

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