1. Surgical management of perforated ulcer: primary closure with graham patch
-If there is a history of ulcers through medical treatment (PPIs etc), or a medical need for daily NSAID use, consider doing a highly selective vagotomy procedure at the same time.
-If the patient starts to look septic, or the ulcer looks like its been perforated for a while (>12 hours), then just do the primary repair and get out ASAP.
2. ICU patient that starts to get coffee ground emesis or coffee ground drainage from NG: think ulcer. Treat empirically. If the blood turns bright red, resuscitate with IVF, type & cross, then endoscopy.
3. Endoscopic findings:
-duodenal ulcer with white base: hasn't bled recently, unlikely to bleed. Treat with PPIs/H2 blockers to keep pH>5
-duodenal ulcer with adherent clot: has bled, 10-15% chance of rebleed soon. Mange with endoscopic methods-- injecting epi or sclerosing agents, argon or laser coagulation, suturing.
-duodenal ulcer on top of giant artery: local control endoscopically, go to the OR for definitive repair (i.e. oversewing vessel) within next 24-48 hours.
-duodenal ulcer in ESRD: coagulopathy 2/2 uremia treat with DDAVP or FFP, ESLD: coagulopathy 2/2 platelet sequestration (transfuse, or DDAVP), defect in coagulation factors (FFP/cryo), portal hypertension.
-Gastric ulcer: biopsy to r/o cancer once the bleeding is under control (i.e. within 2 weeks)
4. Gastritis: erosions without ulcers, common in ICU, burns, sepsis, increased ICP, vent patients, trauma, renal failure, etc. Keep pH>5. If that doesn't work, and it still bleeds, you will need to cut out whatever stomach is bleeding-- endoscopic or partial surgery doesn't work.
5. Acute management of bleeding from esophageal varix:
-First: IVF/blood resuscitation, FFP/cryo, platelets (if they are thrombocytopenic), B-blocker, IV octreotide (or vasopressin but that causes coronary vasoconstriction and is CI in people that are old or have a cardiac history), GI banding/ligation
-If that doesn't work: re-scope, band/ligate/sclerose again.
-If that doesn't work: tamponade balloon such as Minnesota (can cause esoph/stomach necrosis, can increase aspiration risk so only can do in people who are intubated, only works while inflated), TIPS, go to OR for portosystemic shunt (50% mortality in emergent cases of people who have bad ESLD)
6. Prevention of future bleeding after successful control of acute variceal bleed:
-In people who have good synthetic liver function and good overall health, TIPS or portosystemic shunt can offset the need for transplant for 5-10 years
-In people who don't have good synthetic liver function, a shunt procedure can be devastating, list them for transplant.
7. Gastric lymphoma:
-Staging: CT C/A/P with IV and PO contrast to look for other tumor, biopsy enlarged nodes, check waldeyer's ring.
-If it's MALToma, eradicate H.Pylori usually cures it.
-If it's stage I or II, surgery, III or IV, chemoradiation.
8. GB: 
-Asymptomatic gallstones: <10% of patients will develop symptoms requiring surgery over 5 years, no surgery unless they are high risk (immunocompromised and can't tolerate sepsis, people with porcelain GB or stones > 3cm since they are assoc with GB cancer development)
-RUQ pain, no fever, doesn't look toxic, mild leukocytosis (<15), mild jaundice: likely biliary colic, schedule surgery. NO antibiotics.
-RUQ pain, fever, thickened GB wall and stones: acute cholecystitis. Usually GNR and anaerobes (e.coli, enterobacter, kelb, enterococcus), treat with 2nd gen cephalosporins with anaerobic coverage (cefotetan, cefoxime). IVF, NPO, NG tube if they are vomiting or nauseous. Lap chole within 2-3 days.
-RUQ pain, fever, stones + elevated LFTs and very elevated bili: probably CBD stone. See other post for determining risk of CBD stone (in brief: Tbili>4 or seeing a stone in CBD on u/s: ERCP for stone removal; if the CBD > 6mm and Tbili 2-3, MRCP then ERCP if its positive). If there's a stone, ERCP then lap chole, or lap chole with intraop cholangiogram.
-GB cancer: open chole + wide resection of liver, with 2-3 cm margins around GB.
-Polyp: excise if >2cm in size because of 7-10% risk of developing adenocarcinoma.
-Porcelain GB: 50% risk of developing adenocarcinoma.
9. Hepatic masses:
-cyst with no internal echoes: simple cyst, leave it alone or if there are symptoms, drain and inject w sclerosing agent
-cyst with internal echoes: likely echinococcal cyst, inject w sclerosing agent
-cyst + signs of systemic infection: bacterial/amebic abscess. Serologies to r/o amebic abscess. Drain bact abscess + abx, flagyl for amebic abscess.
-hepatic adenoma: assoc with OCP use, resect if it's big because there's a greater chance of rupture (esp during pregnancy)
-solid mass: r/o hemangioma (w tagged RBC scan), then biopsy. Check afp, cea.
10. Resectable HCC:
-1 cm  margins attainable
-not invading vessels
-<5cm in size
-solitary
-noncirrhotic liver
-NO METS (look at hepatic hilar nodes, celiac nodes, diaphragm, local structures). CT C/A/P to look for mets.