GI & Surgery Flashcards
Achalasia
Degenerative loss of nerves in Auerbach’s plexus leads to failure of relaxation of LOS
= dysphagia of liquids and solids, regurg, heartburn, cough
Inv - oes manometry (inc LOS tone), barium swallow (fluid level, bird beak), CXR (wide mediastinum)
-> balloon dilatation, Heller cardiomyotomy, botox
Pharyngeal Pouch
Posteromedial herniation between thryopharyngeus and cricopharyngeus muscles (killian’s).
RF - old, 5M:F
= dysphagia, bad breath, gurgling on swallowing, cough, regurg, aspiration
Inv - barium swallow + dynamic video fluoroscopy
-> surgery
Oesophageal Cancer
Squamous (upper 2/3)
- Linked with PV, smoking, alcohol, achalasia, nitrosamines in diet.
Adeno (lower 1/3, most common)
- Linked with GORD, Barrett’s, smoking, obesity
= dysphagia, anorexia, weight loss, vomiting, odynophagia, hoarse, melaena, cough
Inv - upper GI scope + biopsy, endo US to locally stage, CT TAP
-> surgical resection (anastomotic leak and mediastinitis risk), adj chemo
Plummer-Vinson syndrome
Triad of iron deficient anaemia, dysphagia (oes webs) and glossitis
-> iron supp, web dilation
Other Causes of Dysphagia
Oesophagitis - heartburn, pain, no weight loss, systemically well
Candidiasis - Hx HIV or steroid inhaler use
SS - other CREST features (v LOS pressure)
Myasthenia Gravis - extraocular muscle weakness and ptosis
Globus - painless, swallowing helps, Hx anxiety
GORD
Reflux of stomach contents into the oesophagus.
= heart burn, regurg, nocturnal cough, epigastric pain, hoarseness
Referral for upper endoscopy if;
- >55, weight loss, dysphagia, symptoms >4 weeks or no response to treatment
Consider 24hr oes pH monitoring if negative
Comp - oesophagitis, ulcers, anaemia, strictures, Barrett’s, oes cancer
Management of GORD
Lifestyle advice - reduce tea, coffee, weight, smoking, stand after meals, smaller meals
Endoscope +ve -> full dose PPI for 1-2 months
- Response: low dose as required
- No response: double for 1month
Endoscope -ve -> full dose PPI for 1 month
- Response: low dose as required
- No response: prokinetic or H2RA 1 month
Mesenteric Ischemia
RF - age, AF, cancer, CVD RF and cocaine (ischemic colitis).
Acute
= severe sudden abdo pain»_space; exam, PR blood
Inv - ^WCC, lactic acidosis
-> immediate laparotomy
Chronic
= intestinal angina, colicky
Ischemic colitis
= acute but transient loss (^splenic flexure)
Inv - AXR (thumbprinting), CT (segmental thickening of large bowel wall, pericolic fat stranding)
-> conservative
Biliary Colic
^cholesterol, biliary stasis and v bile salts = stone formation = obstruction and colic
RF - fat, female, fertile, 40, DM, Crohn’s, rapid weight loss, fibrates, COCP
= colicky RUQ pain, radiates to R shoulder, worse after fatty foods, n+v, NO FEVER, NORMAL BLOODS
Inv - US
-> elective lap cholecystectomy
Acute Cholecystitis
Inflammation of the gallbladder
90% due to calculi, 10% severely ill/ IC patients 2nd to cryptosporidium or CMV
= RUQ pain, to right shoulder + FEVER and systemic upset, murphys +ve
Inv - normal LFT unless Mirizzi syndrome (in distal cystic duct compress CBD), US, HIDA if unclear
-> IV Abx, lap chole within 1 week
Gallstone complications
Mucocele
Abscess/ empyema (swinging fever, US +/- CT)
Gallstone ileus (remove stone, don’t touch GB)
Ascending Cholangitis
Bacterial infection of the biliary tree (^^E.coli)
RF - gallstones, ERCP
= Charcot’s fever (rigors), RUQ pain and jaundice,
Reynolds pentad is hypotension and confusion
Inv - ^LFT, ^inflam, blood cultures, US (dilated BD/ stones), MRCP (CT overnight)
-> IV fluids, IV Abx, ERCP to relieve obstruction
Drugs causing cholestasis
COCP
Fluclox, co-amoxiclav and erythromycin
Testosterone, anabolic steroids
Sulphonylurea
Fibrates
Chlorpromazine
Drugs causing hepatocellular picture
Paracetamol
Phenytoin
Sodium valproate
Statins
Alcohol
Amiodarone
Methyldopa
MAOI
TB drugs
Nitrofurantoin
Chronic Pancreatitis
80% due to alcohol excess, 20% unexplained
Other causes - CF, haemochromatosis, tumour, stones, pancreas divisum and annular pancreas
= severe abdo pain 15-30 min after meal, steatorrhea (5-25yrs), DM (20yrs)
Inv - AXR (calcification), CT best, faecal elastase to assess exocrine function
-> enzyme supplements, analgesia
Acute Pancreatitis
Autodigestion of pancreatic tissue
Causes - I GET SMASHED
= severe epigastric pain, through to back, n+v, low-grade fever, ileus, Cullen’s (periumbilcial) or Grey-Turner’s (flank), rarely retinopathy
Inv - amylase (3x upper limit), lipase (longer half life), early US for cause, CT diagnose if unsure, ABG for score
-> fluid resus, analgesia, antiemetics, no need for NBM (enteral feeding is used if moderate or severe) and no prophylactic Abx, 4hourly glucose, AC
Glasgow scoring system
Severity of Pancreatitis. Score of 3 is severe.
Pa02 - under 8
Age - over 55
Neutrophils - over 15
Calcium - under 2
Renal - urea over 16
Enzymes - LDH over 600 or AST over 200
Albumin - under 32
Sugar - over 10
Acute Pancreatitis - Causes
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion
Hyperlipidaemia
ERCP
Drugs - azathioprine, mesalazine, thiazides and furosemide
Diarrhoea ABG
Anion Gap = all positive ions - negative ions Normally 10-18
Diarrhoea
Loss of bicarb and K from GI tract - hypokalemia metabolic acidosis
Hep A
RNA picornavirus, faecal-oral spread
= self-limiting, flu-like prodrome, RUQ pain, tender hepatomegaly, jaundice
Inv - ^LFTs
No inc risk of HCC
Vacc - travelling, CLD, gay M, IVDU, occupational
Hepatitis B
dsDNA hepadnavirus,
Spread via body fluids and vertical transmission
Comp - chronic Hep (ground glass hepatocytes), HCC, GN, polyarteritis nodosa and cryoglobulinaemia
-> antivirals, pre interferon-a
Hep B Serology
HBsAg - first marker, active infection if positive (acute <6m and chronic >6m)
Anti-HBs - immunity (exposure and immunized)
Anti-HBc - c for caught (previous or current)
- IgM acute
- IgG persists
Anal Fissure
Longitudinal tears of the squamous lining, acute <6wks
RF - constipation, IBD, STI (HIV, herpes, syphilis)
= painful bright red bleeding, posterior midline (? cause if not)
-> (acute) diet advice. bulk-forming laxities, lubes, analgesia, anesthetic cream
(chronic) GTN for 8 weeks, no response then refer for sphincterotomy/botox
Primary Biliary Cholangitis
AI inflam of interlobular bile ducts = cholestasis
Link - Sjogren’s, RA, SS, thyroid
= middle-age F, itching, jaundice, RUQ pain, hyperpigmentation (pressure points), xanthelasma, clubbing, organo, liver failure
Inv - AMA, ASMA, IgM, ALP, US/ MRCP
-> urodeoxycholic acid (slows progression), cholestyramine, fat-sol vitamins, transplant (BR >100)
Comp - cirrhosis, portal HTN, ascites, varices,
osteomalacia/porosis, 20 x HCC
Primary Sclerosing Cholangitis
Inflammation and fibrosis of the intra and extra hepatic bile ducts
Link - UC, HIV, Crohn’s
= cholestasis (jaundice, pruritis), RUQ and fever
Inv - ^BR, ^ALP, MRCP diagnosis, some p-ANCA+
Comp - 10% risk of cholangiocarcinoma, CRC
UC Flare
Mild - <4 shits, minimal blood, normal CRP
Moderate - 4-6, minor systemic
Severe - >6, blood, systemic upset (fever, ^HR, anaemia, v albumin)
Inducing remission:
Proctitis -> rectal ASA, add oral if need at 4wks, add PO steroid
Left-sided -> rectal ASA, add oral (can swap top for steroid), oral steroid and oral ASA
Extensive -> rectal ASA and oral ASA, add oral steroid
Severe-> hospital, IV steroids, add IV ciclosporin
UC Maintenance
Proctitis -> top ASA (+/-) oral ASA
Left sided/ extensive -> oral ASA
Severe or 2+ in year -> oral Azathioprine or mercaptopurine
Crohn’s Management
Inducing Remission
-> Steroids, 5-ASA, add azathioprine or mercaptopurine, infliximab if fistula/ refractory
Maintenance
-> Azathioprine or mercaptopurine
Perianal fistulae
- MRI, metronidazole, draining seton if complex
Abscess
- incision and drain with Abx, draining seton
A1AT deficiency
AR, Chr14, normally protects cells from neutrophil elastase
= emphysema in lower lobes, cirrhosis and HCC in liver, cholestasis in kids
Inv - spirometry (obstructive), A1AT conc
-> no smoking, physio, BD, lung vol reduction surgery, transplant
Gilberts Syndrome
AR, UDP glucuronosyltransferase deficiency.
BR not conjugated so get unconjugated hyperbilirubinemia (not in urine)
= jaundice when stressed, ill or exercising
No treatment
Upper GI bleed - Scoring
Glasgow-Blatchford - manage as in/outpatient
Rockall - after endoscopy, % of chance of rebleed and mortality
Management of Variceal Upper GI Bleed
Terlipressin and proph Abx
Endoscopy <24hrs - band ligation
If uncontrolled use Sengstaken Blakemore tube
TIPSS if all else fails
Prophylaxis of variceal - propranolol
TIPSS
Connection between the hepatic and portal vein
Blood route that bypasses the liver (v portal HTN)
Management of Non-Variceal Upper GI bleed
Endoscopy <24hrs
PPI given if evidence of GI bleeding and stigmata of recent haemorrhage on endoscopy
Gallstone Ileus
Small bowel obstruction 2nd to impacted gallstone, through GB-duodenum fistula
= vomiting, pain, distension, pneumobillia on XR
Don’t touch the GB
Inguinal Hernias
Most common abdo wall hernias, 95% M
= superomedial to pubic tubercle, disappears lying/ pressure, aching, rarely strangulate
Direct - defect in posterior wall of inguinal canal
Indirect - via deep inguinal ring (patent processus)
-> treat if med fit, open unilateral or lap bilateral
treat infant if presenting in first months of life (high risk of strangulation)
Vit C deficiency
Ascorbic acid, for collagen synthesis
Found naturally in citrus fruits, tomatoes, cauliflower, brocoli, cabbage and spinach
= ecchymosis and easy bruising, poor wound healing, bleeding gums, lose teeth, arthralgia, malaise
C.diff
Gram-positive rod, produces exotoxin
RF - clindamycin, cephalosporins, PPIs
Classification:
Mild - normal WCC
Moderate - WCC <15 and 3-5 loose stools
Severe - WCC >15, temp >38.5, severe colitis evidence
Life threatening - v BP, ileus, toxic megacolon
Inv - stool toxin, antigen only shows exposure
Management of C.diff
First episode
-> oral vancomycin, fidaxomicin 2nd, oral vanc +/-
IV met 3rd
Recurrent <12wks
-> fidaxomicin
Life-Threatening
-> oral van + IV met
C.diff drugs to stop
Stop antimotility drugs and anti-peristaltic Opioids - inc risk of toxic mega colon.
Other Abx - stop return of normal gut flora
Budd-Chiari
Hepatic vein thrombosis
Causes - pregnancy, COCP, thrombophilia, polycytheamia RV
= sudden severe abdo pain, abdo distension and tender hepatomegaly
Inv - doppler flow studies
Boerhaave’s syndrome
Spont rupture of oesophagus 2nd to vomiting.
Normally distal and on the left hand side.
= sudden severe chest pain, SC emphysema
Inv - CT contrast swallow
-> thoracotomy and lavage, surgery if <12 hours, T tube after (controlled fistula)
Wilson’s
AR, excessive copper deposition, defect in ATP7B gene on chr 13.
= onset 10-25yrs, liver in kids, neuro in adults
Liver - hepatitis and cirrhosis
Neuro - basal ganglia degen (symmetrical Parkinsonism), psych/ behaviour issues, asterixis, chorea, dementia, double panda sign (MRI)
Keyser Fleisher - brown rings in iris, Cu in Descemet membrane
Blue nails
Fanconi syndrome (RTA)
Inv - slit lamp, v serum caeruloplasmin, v total copper, ^free copper, genetic analysis confirms, 24hrs urinary copper, biopsy
-> penicillamine or trientine hydrochloride
Raised ALP
Biliary obstruction - gallstone, cholangitis, cancer, stricture, fluke, PSC, pancreatitis
Liver disease
Paget’s
Bone mets
Osteomalacia
Hyperparathyroid/ thyroid
Renal failure
Pregnancy and growing kids
Haemochromatosis
AR, Chr 6 HFE gene, 1 in 10 Europeans carr
= asymp early, fatigue, erectile dysfunction, arthritis (hands), DM, liver, hypogonadism, bronze skin and dilated CM (reversable)
Inv - ^transferrin saturation, ^ferritin, v TIBC, MRI, genetic testingof family
-> venesection (keep transferrin sat <50% and ferritin <50), deferoxamine 2nd
Peritoneal Dialysis
RRT, younger pts/ less hospital visits
Continuous Ambulatory Peritoneal Dialysis (CAPD) involves four 2L exchanges/day
Comp - peritonitis (staph epidermidis or aureus)
-> vancomycin and ceftazadime
Ascites
Serum ascites albumin gradient (>/< than 11g/L)
Above: portal HTN
Liver - cirrhosis, mets, alcohol
Cardiac - constrictive pericarditis, RHF
Budd chiari, myxoedma
Below:
Low albumin - nephrotic, malnutrition
Infection - TB
Pancreatitis, bowel obstruction
-> fluid restrict if low sodium, reduce sodium in diet, spironolactone
If tense (painful) use large volume paracentesis with albumin cover
If protein in fluid <15 offer ciprofloxacin for Ab prophylaxis
SBP
Form of peritonitis usually seen in patients with ascites secondary to cirrhosis (^^E.coli)
= ascites, abdo pain, fever
Inv - paracentesis (neutrophils >250)
-> IV cefotaxime
Abx prophylaxis if ascites +
prev. SBP or fluid protein <15 (with child pugh 9+ or HRS)
- Oral ciproflox
FAST Scan
US, used in trauma to assess the extent of free fluid in the chest, peritoneal or pericardial cavity.
IBS
= abdo pain, bloating, change in bowel habit >6mths
Inv - FBC, ESR/CRP, coeliac screen
Pain - antispasmodics
Constipation - laxatives (not lactulose), if fails try linaclotide
Diarrhoea - loperamide
If above not working try TCA
Omeprazole vs Lansoprazole
Omeprazole has an interaction with clopidogrel whereas the latter does not
Management of Nausea in Migraine
Pro-kinetic agents are used to help relieve gastric stasis and slow the transit and absorption of the drug used in acute migraine attacks
E.g., metaclopramide
Long term feeding options
Can stomach function?
Yes;
Short term - NG/ND/ NJ tube. If long term then use PEG tube
No:
Short term - peripheral parenteral nutrition
Longer term - central parenteral nutrition
Investigating IBD
Normally a colonoscopy is best
If severe colitis UC is investigated with flexy sig due to risk of perf. Note colitis is the finding. In history rare sign but may be incontinence.
Hartmanns procedure
Used in emergency obstruction caused by a cancer. This is because anastomosis is not used in emergency.
In this procedure there is removal of the obstructed segment (it is the sigmoid and sometimes part of rectum - proctosigmoidectomy) and then an end colostomy is made
Gastric Cancer
RF - older, M, H. pylori, atrophic gastritis, salt and salt-preserved foods, nitrates, smoking, blood group A
= vague/ epigastric abdo pain, dyspepsia, weight loss, anorexia, n+v, left supraclavicular lymph node (Virchow’s), periumbilical nodule (Sister Mary Joseph’s)
Inv - OGD with biopsy (signet ring cells), CT staging
-> endo mucosal resection, partial/ total gastrectomy, chemo
Solitary Rectal Ulcer Syndrome
Cause - chronic constipation
= pain, bleeding
Inv - histology shows mucosal thickening with collagen deposition (fibromuscular obliteration)
Haemorrhoids
Enlarged vascular cushions, internal or external depending (dentate line), 3, 7, 11
Graded on ability to prolapse
1 - No Prolapse
2 - Prolapse but go back on own
3 - Prolapse and need to be reduced by self
4 - Always prolapsed
Management of Haemorrhoids
Soften stool (inc fibre and fluid)
Top anaesthetics/ steroids
Rubber band ligation
Surgery for large symp not responding
Thrombosed - acutely painful and purplish. Excise if present within first 72 hours. Otherwise use stool softeners and ice packs
Pathology of Alcoholic Liver Disease
- Alcohol related fatty liver
- Alcoholic hepatitis - in acute disease steroids can be used to manage
- Cirrhosis - scar tissue replaces healthy tisssue
Stigmata of CLD
Jaundice
hepatomegaly
Spider Naevi
Palmar Erythema
Gynaecomastia
Bruising
Ascites
Caput Medusae
Astrexis
Liver Cirrhosis
Scar tissue replaces normal liver tissue increasing resistance in vessels = portal hypertension
Causes - alcohol, NAFLD, hep B and C
In decompensated all LFTs are deranged. In alcoholic AST > ALT and in NAFLD opposite
ELF - first line in assessing cirrhosis in NAFLD
US - if above not available.
Fibroscan / Transient elastography - every 2 years if heavy alcohol, Hep C, Alcoholic liver, NAFLD or chronic Hep B to assess level of fibrosis
Scoring systems in Liver Disease
Child Pugh: severity of cirrhosis and prognosis. Each scored out of 3
Billirubin
Albumin
INR
Ascites
Encephalopathy
MELD:
Used every 6 months in those with compensated cirrhosis to give 3 month mortality
BR, creatinine, INR
Cirrhosis: Monitoring
US and AFP - 6 months
Endoscopy - 3 years
MELD - 6 month
Malnutrition - Cirrhosis
Cirrhosis impacts the metabolism of proteins in the liver = decreased production. Also impacts storage and release of glycogen
Management - low sodium and high protein / calorie
Portal HTN - Cirrhosis
Portal vein delivers blood to the liver (from SMV and splenic vein)
In cirrhosis there is inc resistance in blood flow = inc back flow of pressure. Causes vessels at anastomosis sites to become swollen:
Gastro-oesophageal junction
Ileocaecal Junction
Rectum
Anterior abdo wall - caput medusae
Ascites - Cirrhosis
-Fluid in peritoneal cavity. Caused by portal HTN. This drop in circulating volume can lead to reduced Bp entering kidneys.
This is sensed and so renin released. Via aldosterone more sodium and fluid is reabsorbed.
-> low sodium diet, aldosterone antagonists, parecentesis
Hepatorenal Syndrome
Portal HTN means the vessels in the portal system are stretched and dilated. Blood pools here
This means less blood volume in the kidneys. RAAS is activated which causes renal vasoconstriction. - blood starvation
Hepatic Encephalopathy
Liver cirrhosis prevents the metabolism of ammonia. Also because of portal HTN there is collateral vessels that form between portal and systemic circulation. Means ammonia can bypass the liver and enter systemic system
1 - irritable
2 - confusion / inappropriate
3 - restless / incoherent
4 - coma
Lactulose given to manage. Can also give rifaximin - reduces bacteria producing lactulose.
NAFLD
Most common cause of liver disease in developed world, hepatic manifestation of metabolic syndrome
Steatosis -> steatohepaitits -> fibrosis and cirrhosis
RF - obesity, T2DM, high lipids, smoking, sudden weight loss, jejunoileal bypass
Inv - ALT>AST, US (^echogen), enhanced liver fibrosis blood
-> weight loss, smoking cessation, control of comorbidities
Liver Cancer
HCC (80%)
RF - (cirrhosis) hep B, hep C, alcohol, haemochromatosis, PBC, A1AT
US+/- AFP
Cholangiocarcinoma (20%)
RF - PSC
= persistent biliary colic, palpable RUQ mass
CA19-9
Liver Transplant
Used in Acute liver failure (hepatitis or paracetamol) or chronic liver failure.
Contra - sig comorbid, active hepatitis, end stage HIV and active alcohol use (6m abstinence)
Kings college LT guidelines for Paracetamol OD
Infective Causes of Diarrhoea
Campylobacter - recent travel. Blood stools.
E.coli - recent travel. Stomach cramps and non- bloody diarrhoea.
Hernia terms
Strangulated: irreducible, base cuts off blood supply
= sig pain and tenderness
Incarcerated: can’t be reduced back but is not painful.
Weird Hernias
Richters - Only part of the bowel wall and lumen herniate but the other half does not.
Madyls - two different parts of bowel have herniated
Spigelian - Between the lateral border of the rectus abdominus and line seminlunaris.
Diastasis Recti - Normally after pregnancy. Widening of the line alba
RIF pain on PR
Appendicitis
Investigation after anastamosis
Gastrografin enema is used to see if the joining has healed properly and ensure no leaking.
Hyatid Cysts
Common in Middle Eastern and Mediterranean countries
They form an outer capsule with multiple daughter cysts
US is often used first line but CT is the best to differentiate from diff kinds of cysts
Mebendazole and surgery to treat
Blood gas in vomiting
Metabolic alkalosis - due to H+ ions being lost - with a low K+
Autoimmune Hepatitis
Type 1 - Both Adults and Kids. ANA and anti smooth muscle
Type 2 - children. AL/KM (anti liver / kidney)
Type 3 - middle aged adults. soluble liver antigen
= CLD, fever, jaundice, amenorrhea
All have raised IgG, biopsy (inflam, necrosis)
-> steroids, IS, transplant
Small Bowel Bacterial Overgrowth Syndrome
RF - DM, scleroderma and neonates with GI issues
= chronic diarrhoea, bloating and pain
Inv- hydrogen breath test
-> rifaximin to treat
Dyspepsia referral
All with dysphagia
All with upper abdo mass = stomach cancer
Aged over 55 with weight loss and one of;
reflux
dyspepsia
Upper abdo pain
Coeliac Disease
AI inflam, small bowel (j), autoantibodies to gluten protein (gliadin)
RF: F, FHx, HLA-DQ2/8
= fatigue, diarrhoea, steatorrhea, n+v, bloating, abdo pain, weight loss, vit def, dermatitis herpetiformis (itchy blistering extensor, IgA in dermis)
Eat gluten 6 wks -> total IgA, anti-TTG, anti-endomysial, endoscopy + biopsy (villus atrophy, crypt hypertrophy, lymph infiltration)
Comp - hyposplenism (peum vac 5yrly), enteropathy-associated T-cell lymphoma of SI
Bowel obstruction
Cause - adhesions (small), tumour (large)
Inv - abdo XR, CT definitive
Dilated if small bowel is >3cm diameter, >9cm for caecum, 8cm for ascending colon, and >6cm for recto-sigmoid
NBM, drip and suck
Unknown GI bleed
FBC, coag, crossmatch, G&S!!
PR and proctoscopy
OGD
CT angiogram (triple phase)
Colonic bleed
Resection or interventional embolization (tertiary)
Wound dehiscence
Saline soaked gauze, senior input, prep for surgery (bloods, NBM)
Surgical ward round
History, exam, look at notes
? NEWS, bloods, fluid chart, drugs
Look at drains, wounds, NG, catheter, stoma
Ask about pain, n+v, eating, drinking, bowels (flatus), urine, breathing, mobilisation
Barrett’s
Reflux of acid causes metaplasia of squamous epithelium to columnar.
RF - GORD, 7M:F, smoking, central obesity
Management - high-dose PPI, endoscopy every 3-5 years if metaplasia, if dysplasia seen then RF ablation or endo resection
Pancreatic Cancer
80% adenocarcinoma, at head, present late
RF - age, smoking, DM, chronic panc, HNPCC, MEN, BRCA2, KRAS
= painless jaundice, pale stool, dark urine, pruritus, GB/ epigastric mass, DM, atypical back pain, migratory thrombophlebitis (Trousseau)
Inv - US, high res CT best (double duct - CBD and panc)
-> Whipple’s, adjuvant chemo, ERCP and stent for palliative
H. Pylori Eradication
Gram-ve bacteria
Link - peptic ulcer, 95% of duodenal ulcers, 75% of gastric ulcers, gastric cancer, B cell lymphoma of MALT tissue, atrophic gastritis
Inv - urea breath test (no Abx for 4wk, no PPI for 2wk, can check eradication)
-> 7d PPI + amoxicillin + clarithromycin/ metronidazole
