HEPATITIS A & B

Hepatitis is an inflammation of the liver, most commonly caused by a viral infection. There are five main hepatitis viruses, referred to as types A, B, C, D and E. These five types are of greatest concern because of the burden of illness and death they cause and the potential for outbreaks and epidemic spread. In particular, types B and C lead to chronic disease in hundreds of millions of people and, together, are the most common cause of liver cirrhosis and cancer. Hepatitis A and E are typically caused by ingestion of contaminated food or water. Hepatitis B, C and D usually occur as a result of parenteral contact with infected body fluids. Common modes of transmission for these viruses include receipt of contaminated blood or blood products, invasive medical procedures using contaminated equipment and for hepatitis B transmission from mother to baby at birth, from family member to child, and also by sexual contact. Acute infection may occur with limited or no symptoms, or may include symptoms such as jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.

Hepatitis A
Hepatitis A is a disease caused by the hepatitis A virus that results in inflammation of the liver. Formerly, hepatitis A was called infectious hepatitis. In children the disease is usually mild, but most adults who develop hepatitis are sick enough to miss four to six weeks of work. How is the virus spread?
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The hepatitis A virus is found in the feces (stool) of infected persons and is usually spread by the fecaloral route. Hepatitis A may be spread by food prepared or handled by an infected person who does not wash his/her hands carefully. Hepatitis A may be spread by water contaminated with human feces or by consumption of raw oysters. It may also be spread by close intimate contact (household or sexual) and by changing the diaper of an infected child.

What are the symptoms of hepatitis A? Symptoms Children with hepatitis A usually have no symptoms. Adults may become quite ill suddenly, experiencing jaundice, fatigue, nausea, vomiting, abdominal pain, dark

urine/light stools, and fever. The incubation period averages 30 days. However, an infected individual can transmit the virus to others as early as two weeks before symptoms appear. Symptoms will disappear over a 6 -12-month period until complete recovery occurs. The first symptoms are usually:
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Fever Loss of appetite Nausea Vomiting Malaise

This is usually followed by dark colored urine and jaundice (yellowing of the skin and the whites of the eyes). In general, the severity of illness increases with age and children under age three may not have symptoms, though they can still spread the infection. Most people feel better after one to two weeks, but may continue to feel tired for a few more weeks. How soon do symptoms appear? Usually the first symptoms appear at about one month, but can develop anytime between two and six weeks after exposure to the virus. How long can an infected person spread the virus? People are most infectious in the two weeks before their symptoms appear and remain somewhat infectious about one week after jaundice. Can a person get hepatitis A again? After one infection with hepatitis A, a person cannot get it again. However, there are different types of viral hepatitis, and infection with hepatitis A will not protect against other types of hepatitis. What is the treatment for hepatitis A? There is no specific treatment for hepatitis A. Bed rest is generally all that is needed. Infected persons should also avoid alcohol, drugs, or medicines (including aspirin and Tylenol), without checking with a doctor. What can be done after a person is exposed to a person infected with hepatitis A?

Immune globulin (IG) is given to family members and close contacts (including sexual) of persons with hepatitis A. o The best time to get the shot is within two weeks after contact with someone who has hepatitis A. o IG is not recommended for people who have limited contact with an infected person such as at school, work or a brief visit to his or her home.

How Does it Spread? Hepatitis A is most often spread from person to person through situations such as these:
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Food preparers who are infected can pass the virus on if they do not wash their hands with soap and water after having a bowel movement, especially when they prepare uncooked foods. Fecal contamination of food and water. Anal/oral contact, by putting something in the mouth that had been contaminated with infected feces. Diaper changing tables, if not cleaned properly or changed after each use, may facilitate the spread of HAV. Fecal residue may remain on the hands of people changing soiled diapers. Eating raw or partially cooked shellfish contaminated with HAV.

How can the spread of hepatitis A be stopped?

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The spread of hepatitis A can be stopped by always washing hands thoroughly after using the toilet or changing a diaper. Children should be taught to wash their hands with soap and warm water after using the toilet. Washing hands before preparing food is very important. Hepatitis A vaccine is now available in the U.S. for persons 2 years of age or older. o To be fully immunized, a person needs a second injection of vaccine 6 to 12 months after the first injection. o The vaccine is recommended for anyone traveling to an endemic area. o Persons who eat out frequently, children who attend childcare centers, or people who engage in high-risk activities should consider immunization for hepatitis A. o Clark County food handlers and child care workers are required to be immunized against hepatitis A.

Diagnosis Your doctor can't single out Hepatitis A from other types of viral hepatitis based upon your physical symptoms alone. The only way to diagnose HAV is to do a blood test seeking to find IgM antibodies. In most people, these antibodies become detectable 510 days before the onset of symptoms and can persist for up to 6 months after infection.

Outcome Hepatitis A will clear up on its own in a few weeks or months with no serious after effects. Once recovered, an individual is then immune for life to HAV through the presence of the IgG antibody . About 1 in 100 HAV sufferers may experience a sudden and severe (i.e., "fulminant") infection.

Preventing Hepatitis A (HAV)

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Vaccinate. Immunization of children (1-18 years of age) consists of 2 or 3 doses of the vaccine. Adults need a booster dose 6-12 months following the initial dose of vaccine. The vaccine is thought to be effective for 15 - 20 years or more. Vaccines to prevent HAV infection prior to exposure provide protection against the virus as early as 2 4 weeks after vaccination. Other people who should be vaccinated include: Users of illegal injected drugs. Restaurant workers and food handlers. Young people living in dorms or in close contact with others. Children living in communities that have high rates of hepatitis. Children and workers in day care centers. People engaging in anal/oral sex. People with chronic liver disease. If you eat raw shellfish frequently, ask your physician about being vaccinated. Laboratory workers who handle live hepatitis A virus. Common sense hygiene. Hands should be washed with soap and water following bowel movements and before food preparation. Traveler precautions. People who travel to developing countries where sanitary conditions are poor should be vaccinated two months prior to departure. For those exposed to HAV, immune globulin (IG) should be given as soon as possible and no later than 2 weeks after initial exposure.

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Hepatitis B (Serum Hepatitis)

Hepatitis B is caused by a highly contagious virus that infects the liver. In the past, hepatitis B was called serum hepatitis. Many people, especially children, have mild or no symptoms following infection with the virus. However, long-term infection can occur and may lead to liver disease, cancer or death. Who gets hepatitis B? Anyone can get hepatitis B. However, certain groups have a greater chance of becoming infected. These include:
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Infants born to infected mothers IV drug users Sexual partners of infected people People with many heterosexual, homosexual or bisexual partners Certain populations with high rates of hepatitis B infection Heath care workers Public safety workers Anyone who has frequent contact with blood Clients and staff of institutions for the mentally retarded Housemates of chronically infected people are at higher risk than the general population, but lower risk than those listed above

How is the virus spread? The hepatitis B virus is usually spread:

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Through sexual activity Contaminated blood and blood products Close household contact From infected mothers to infants at birth (See the Perinatal Hepatitis B Prevention Program for more information.)

What are the symptoms? Symptoms Many people with newly acquired hepatitis B have no symptoms at all, or they may be very mild and flu-like loss of appetite, nausea, fatigue, muscle or joint aches, mild fever, and possibly jaundice (yellowish tinge to the skin). The only way to know if you are currently infected with HBV or if you still carry the virus is to ask your doctor to do a specific blood test for hepatitis B (it may not be included in a routine blood test). The test may not show positive during the incubation period (45-180 days).

Symptoms include:
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Loss of appetite Stomach pain Nausea Vomiting Occasional skin rashes Joint pains Jaundice (yellowing of the skin and the whites of the eyes)

How soon do the symptoms appear? Symptoms develop slowly and may take as long as 45-180 days (average is 60-90 days) to appear after exposure to an infected person. How long can an infected person spread the virus?
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An infected person can spread the virus for several weeks before symptoms appear and as long as the person is ill. Persons who develop lifelong infection (carriers) may spread the virus for their entire lives. Long-term infection may result in liver disease or cancer.

How is hepatitis B diagnosed? There are three standard blood tests for HBV:
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HBsAG (hepatitis B surface antigen): When this test is positive or reactive, you are infected with HBV and can pass it on to others. Anti-HBc (antibody to hepatitis B core antigen): When you test positive, it means you are currently infected with HBV or have been infected at some point in the past. Anti-HBs (antibody to HbsAg): When this test is positive, it means that you are immune to hepatitis B either as a result of having had the disease or from having been given the vaccine.

Can a person get hepatitis B again? If a person develops hepatitis B antibodies, one infection with the hepatitis B virus protects against getting it again. However, there are different types of viral hepatitis, and infection with hepatitis B will not protect against other types of hepatitis.

What is the treatment for hepatitis B? There are two medications to treat chronic HBV Interferon (IFN) and Lamivudine. Less than 50% of patients with chronic HBV are candidates for interferon therapy. Initially, 40% of HBV patients who are treated with IFN will respond. However, some will relapse when the treatment is stopped. Overall, about 35% of the eligible patients will benefit. IFN treatments may have a number of side effects, including flu-like symptoms, headache, nausea, vomiting, loss of appetite, depression, diarrhea, fatigue, and thinning hair. Interferon may lower the production of white blood cells and platelets by depressing the bone marrow. Thus, blood tests are needed to monitor blood cells, platelets, and liver enzymes. The response to oral Lamivudine, given for at least one year, may be somewhat lower. In addition, those who are chronically infected with HBV should be vaccinated against hepatitis A. There is no treatment for acute Hepatitis B. What can be done if a person is exposed to someone infected with hepatitis B?
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When indicated, hepatitis B immune globulin (HBIG) should be given within two weeks after exposure. Hepatitis B vaccine is also recommended for people at high risk of additional exposure. For infants born to infected mothers, the combination of HBIG and vaccine is effective at preventing infection.

How can the spread of hepatitis B be stopped?

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Vaccination is highly protective against the hepatitis B virus. Testing all pregnant women for HbsAg is recommended to prevent spread from infected mothers to their infants. Donated blood should be tested and individuals who test positive should be rejected as donors. Syringes, acupuncture and tattooing needles should never be shared or reused. Personal items such as toothbrushes and razors that could have blood on them should not be shared. Latex condoms should be used regularly if there is more than one partner.

Is there a vaccine to prevent hepatitis B? A vaccine is available and is recommended for all infants at birth as well as for people at high risk of being infected with hepatitis B. The vaccine is safe for most people and the most common complaint is soreness at the injection site. People who receive the vaccine as a precautionary measure may continue to donate blood. How Does It Spread? HBV is found in blood, seminal fluid, and vaginal secretions. The risk of transmission is increased in these situations:

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Sexual contact with an infected person. Living in the same household with an infected individual. Contact with infected blood or seminal fluid and contaminated needles, including tattoo/body piercing instruments. HBV-infected mother to her newborn at time of delivery (prenatal blood tests for HBV should always be done if there is a suspicion of HBV).

Disease Outcome - Either you develop immunity to HBV . . . 95% of adults infected develop antibodies and recover spontaneously within six months. Upon recovery, they develop immunity to the virus and they are not infectious to others. Blood tests will always test positive for the HBV antibody. Blood banks will not accept donations of blood from HBV-immune people. - OR you become chronically infected. About 5% of the time, the virus does not clear the body within six months. If so, a person is considered a carrier or chronically infected. Chronically infected people may or may not show outward signs or symptoms. The HBV virus remains in blood and body fluids, and can infect others.

Preventing Hepatitis B (HBV) Vaccinate. Safe and effective vaccines can prevent HBV. Safe and effective vaccines provide protection against hepatitis B for 15 years and possibly much longer. Currently, the Center for Disease Control and Prevention recommends that all newborns and individuals up to 18 years of age and adult participating at risk of infection be vaccinated. Three injections over a 6-12 month period are required to provide full protection. Newborns exposed to HBV at birth by an infected mother should receive Hepatitis B immune Globulin plus the first dose of hepatitis B vaccine within l2 hours of birth and two additional doses of vaccine at one and six to twelve months of age. All children and adolescents should be vaccinated since most cases of HBV occur in sexually active young adults. Those who engage in high-risk behaviors should be vaccinated as well. Everyone who handles blood or blood products in their daily work should be vaccinated. Practice safer sex (use latex condoms). If you have hepatitis, or if you have more than one sex partner within a six- month period, you should consider

vaccination. Unvaccinated individuals who have been exposed to HBV infected persons through unprotected sex or contact with infected blood or body fluids should receive an intra-muscular injection of hepatitis B immune globulin (HBIG) within l4 days of exposure and the hepatitis B vaccine. Don't share! If you are a user of injected drugs, never share drug needles, cocaine straws, or any drug paraphernalia. No one should share anything that could have an infected person's blood on it (e.g., toothbrush, razor, nail clipper, body piercing instruments, etc.). Handle blood spills correctly. If there is blood spill, even a small one, clean it up with a 10% solution of household bleach (believed to kill the virus). Wear protective gloves.

PEPTIC ULCER
A peptic ulcer, also known as PUD or peptic ulcer disease, is the most common ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. It is defined as mucosal erosions equal to or greater than 0.5 cm. As many as 7090% of such ulcers are associated with Helicobacter pylori, a spiral-shaped bacterium that lives in the acidic environment of the stomach; however, only 40% of those cases go to a doctor. Ulcers can also be caused or worsened by drugs such as aspirin, ibuprofen, and other NSAIDs. Four times as many peptic ulcers arise in the duodenumthe first part of the small intestine, just after the stomachas in the stomach itself. About 4% of stomach ulcers are caused by a malignant tumor, so multiple biopsies are needed to exclude cancer. Duodenal ulcers are generally benign.

Classification
By Region/Location
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Duodenum (called duodenal ulcer) Oesophagus (called esophageal ulcer) Stomach (called gastric ulcer) Meckel's diverticulum (called Meckel's diverticulum ulcer; is very tender with palpation)

Modified Johnson Classification of peptic ulcers:

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Type I: Ulcer along the body of the stomach, most often along the lesser curve at incisura angularis along the locus minoris resistentiae. Type II: Ulcer in the body in combination with duodenal ulcers. Associated with acid oversecretion. Type III: In the pyloric channel within 3 cm of pylorus. Associated with acid oversecretion. Type IV: Proximal gastroesophageal ulcer Type V: Can occur throughout the stomach. Associated with chronic NSAID use (such as aspirin).

Signs and symptoms

Symptoms of a peptic ulcer can be
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abdominal pain, classically epigastric with severity relating to mealtimes, after around three hours of taking a meal (duodenal ulcers are classically relieved by food, while gastric ulcers are exacerbated by it); bloating and abdominal fullness;

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waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus - although this is more associated with gastroesophageal reflux disease); nausea, and copious vomiting; loss of appetite and weight loss; hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer, or from damage to the esophagus from severe/continuing vomiting. melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin); rarely, an ulcer can lead to a gastric or duodenal perforation, which leads to acute peritonitis. This is extremely painful and requires immediate surgery.

Symptoms of a Peptic Ulcer That Need Immediate Medical Attention

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Vomiting blood Vomiting food eaten hours or days before Difficulty swallowing Nausea Black or tar-like stool (indication that there is blood in the stool) Sudden, severe pain in the abdominal area Pain that radiates to the back Pain that doesn't go away when you take medication Unintended weight loss Unusual weakness, usually because of anemia

Complications
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Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be life-threatening. It occurs when the ulcer erodes one of the blood vessels, such as the gastroduodenal artery. Perforation (a hole in the wall) often leads to catastrophic consequences. Erosion of the gastro-intestinal wall by the ulcer leads to spillage of stomach or intestinal content into the abdominal cavity. Perforation at the anterior surface of the stomach leads to acute peritonitis, initially chemical and later bacterial peritonitis. The first sign is often sudden intense abdominal pain. Posterior wall perforation leads to bleeding due to involvement of gastroduodenal artery that lies posterior to the 1st part of duodenum. Penetration is when the ulcer continues into adjacent organs such as the liver and pancreas. Scarring and swelling due to ulcers causes narrowing in the duodenum and gastric outlet obstruction. Patient often presents with severe vomiting. Cancer is included in the differential diagnosis (elucidated by biopsy), Helicobacter pylori as the etiological factor making it 3 to 6 times more likely to develop stomach cancer from the ulcer.

Cause
A major causative factor (60% of gastric and up to 90% of duodenal ulcers) is chronic inflammation due to Helicobacter pylori that colonizes the antral mucosa.The immune system is unable to clear the infection, despite the appearance of antibodies. Thus, the bacterium can cause a chronic active gastritis (type B gastritis), resulting in a defect in the regulation of gastrin production by that part of the stomach, and gastrin secretion can either be increased, or as in most cases, decreased, resulting in hypo- or achlorhydria. Gastrin stimulates the production of gastric acid by parietal cells and, in H. pylori colonization responses that increase gastrin, the increase in acid can contribute to the erosion of the mucosa and therefore ulcer formation. Another major cause is the use of NSAIDs (see above). The gastric mucosa protects itself from gastric acid with a layer of mucus, the secretion of which is stimulated by certain prostaglandins. NSAIDs block the function of cyclooxygenase 1 (cox-1), which is essential for the production of these prostaglandins. COX-2 selective antiinflammatories (such as celecoxib or the since withdrawn rofecoxib) preferentially inhibit cox-2, which is less essential in the gastric mucosa, and roughly halve the risk of NSAID-related gastric ulceration. As the prevalence of H. pylori-caused ulceration declines in the Western world due to increased medical treatment, a greater proportion of ulcers will be due to increasing NSAID use among individuals with pain syndromes as well as the growth of aging populations that develop arthritis. The diagnosis is mainly established based on the characteristic symptoms. Stomach pain is usually the first signal of a peptic ulcer. In some cases, doctors may treat ulcers without diagnosing them with specific tests and observe whether the symptoms resolve, this indicating that their primary diagnosis was accurate. Confirmation of the diagnosis is made with the help of tests such as endoscopies or barium contrast x-rays. The tests are typically ordered if the symptoms do not resolve after a few weeks of treatment, or when they first appear in a person who is over age 45 or who has other symptoms such as weight loss, because stomach cancer can cause similar symptoms. Also, when severe ulcers resist treatment, particularly if a person has several ulcers or the ulcers are in unusual places, a doctor may suspect an underlying condition that causes the stomach to overproduce acid. An esophagogastroduodenoscopy (EGD), a form of endoscopy, also known as a gastroscopy, is carried out on patients in whom a peptic ulcer is suspected. By direct visual identification, the location and severity of an ulcer can be described. Moreover, if no ulcer is present, EGD can often provide an alternative diagnosis. One of the reasons that blood tests are not reliable for accurate peptic ulcer diagnosis on their own is their inability to differentiate between past exposure to the bacteria and current infection. Additionally, a false negative result is possible with a blood test if the patient has recently been taking certain drugs, such as antibiotics or proton pump inhibitors.

The diagnosis of Helicobacter pylori can be made by:

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Urea breath test (noninvasive and does not require EGD); Direct culture from an EGD biopsy specimen; this is difficult to do, and can be expensive. Most labs are not set up to perform H. pylori cultures; Direct detection of urease activity in a biopsy specimen by rapid urease test; Measurement of antibody levels in blood (does not require EGD). It is still somewhat controversial whether a positive antibody without EGD is enough to warrant eradication therapy; Stool antigen test; Histological examination and staining of an EGD biopsy.

The breath test uses radioactive carbon atom to detect H. pylori.[16] To perform this exam the patient will be asked to drink a tasteless liquid which contains the carbon as part of the substance that the bacteria breaks down. After an hour, the patient will be asked to blow into a bag that is sealed. If the patient is infected with H. pylori, the breath sample will contain radioactive carbon dioxide. This test provides the advantage of being able to monitor the response to treatment used to kill the bacteria. The possibility of other causes of ulcers, notably malignancy (gastric cancer) needs to be kept in mind. This is especially true in ulcers of the greater (large) curvature of the stomach; most are also a consequence of chronic H. pylori infection. If a peptic ulcer perforates, air will leak from the inside of the gastrointestinal tract (which always contains some air) to the peritoneal cavity (which normally never contains air). This leads to "free gas" within the peritoneal cavity. If the patient stands erect, as when having a chest X-ray, the gas will float to a position underneath the diaphragm. Therefore, gas in the peritoneal cavity, shown on an erect chest X-ray or supine lateral abdominal X-ray, is an omen of perforated peptic ulcer disease.

Treatment
Younger patients with ulcer-like symptoms are often treated with antacids or H2 antagonists before EGD is undertaken. Bismuth compounds may actually reduce or even clear organisms], though the warning labels of some bismuth subsalicylate products indicate that the product should not be used by someone with an ulcer.[18] Patients who are taking nonsteroidal anti-inflammatories (NSAIDs) may also be prescribed a prostaglandin analogue (Misoprostol) in order to help prevent peptic ulcers, which may be a side-effect of the NSAIDs. When H. pylori infection is present, the most effective treatments are combinations of 2 antibiotics (e.g. Clarithromycin, Amoxicillin, Tetracycline, Metronidazole) and 1 proton pump inhibitor (PPI), sometimes together with a bismuth compound. In complicated, treatment-resistant cases, 3 antibiotics (e.g. amoxicillin + clarithromycin + metronidazole) may be used together with a PPI and sometimes with

bismuth compound. An effective first-line therapy for uncomplicated cases would be Amoxicillin + Metronidazole + Pantoprazole (a PPI). In the absence of H. pylori, longterm higher dose PPIs are often used. Treatment of H. pylori usually leads to clearing of infection, relief of symptoms and eventual healing of ulcers. Recurrence of infection can occur and retreatment may be required, if necessary with other antibiotics. Since the widespread use of PPI's in the 1990s, surgical procedures (like "highly selective vagotomy") for uncomplicated peptic ulcers became obsolete. Perforated peptic ulcer is a surgical emergency and requires surgical repair of the perforation. Most bleeding ulcers require endoscopy urgently to stop bleeding with cautery, injection, or clipping. Ranitidine provides relief of peptic ulcers, heartburn, indigestion and excess stomach acid and prevention of these symptoms associated with excessive consumption of food and drink. Ranitidine is available over the counter from a pharmacy and works by decreasing the amount of acid the stomach produces allowing healing of ulcers. Zantac tablets contain Ranitidine 150 mg as the active ingredient which can also be bought generically. Sucralfate, (Carafate) has also been a successful treatment of peptic ulcer. Gastric and duodenal ulcers usually cannot be differentiated based on history alone, although some findings may be suggestive. Epigastric pain is the most common symptom of both gastric and duodenal ulcers. It is characterized by a gnawing or burning sensation and occurs after mealsclassically, shortly after meals with gastric ulcer and 2-3 hours afterward with duodenal ulcer. In uncomplicated peptic ulcer disease (PUD), the clinical findings are few and nonspecific. Alarm features" that warrant prompt gastroenterology referral include bleeding, anemia, early satiety, unexplained weight loss, progressive dysphagia or odynophagia, recurrent vomiting, and family history of GI cancer. Patients with perforated PUD usually present with a sudden onset of severe, sharp abdominal pain. In most patients with uncomplicated PUD, routine laboratory tests usually are not helpful; instead, documentation of PUD depends on radiographic and endoscopic confirmation. Testing for H pylori infection is essential in all patients with peptic ulcers. Rapid urease tests are considered the endoscopic diagnostic test of choice. Of noninvasive tests, fecal antigen testing is more accurate than antibody testing and is less expensive than urea breath tests. A fasting serum gastrin level should be obtained in certain cases to screen for Zollinger-Ellison syndrome. Upper GI endoscopy is the preferred diagnostic test in the evaluation of patients with suspected PUD. Endoscopy provides an opportunity to visualize the ulcer, to determine the presence and degree of active bleeding, and to attempt hemostasis by

direct measures, if required. Perform endoscopy early in patients older than 45-50 years and in patients with associated so-called alarm features. Most patients with PUD are treated successfully with cure of H pylori infection and/or avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs), along with the appropriate use of antisecretory therapy. In the United States, the recommended primary therapy for H pylori infection is proton pump inhibitor (PPI)based triple therapy. These regimens result in a cure of infection and ulcer healing in approximately 85-90% of cases.[2] Ulcers can recur in the absence of successful H pylori eradication. In patients with NSAID-associated peptic ulcers, discontinuation of NSAIDs is paramount, if it is clinically feasible. For patients who must continue with their NSAIDs, proton pump inhibitor (PPI) maintenance is recommended to prevent recurrences even after eradication of H pylori. Prophylactic regimens that have been shown to dramatically reduce the risk of NSAID-induced gastric and duodenal ulcers include the use of a prostaglandin analog or a PPI. Maintenance therapy with antisecretory medications (eg, H2 blockers, PPIs) for 1 year is indicated in high-risk patients. The indications for urgent surgery include failure to achieve hemostasis endoscopically, recurrent bleeding despite endoscopic attempts at achieving hemostasis (many advocate surgery after 2 failed endoscopic attempts), and perforation. Patients with gastric ulcers are also at risk of developing gastric malignancy.