Stress ulcer

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Stress ulcer
Specialty Intensive care medicine, gastroenterology, digestive system surgery (upper gastrointestinal surgery)

A stress ulcer is a single or multiple mucosal defect usually caused by physiological (not psychological) stress which can become complicated by upper gastrointestinal bleeding. These ulcers can be caused by shock, sepsis, trauma or other conditions and are found in patients with chronic illnesses. These ulcers are a significant issue in patients in critical and intensive care.

Contents

It was previously thought that peptic ulcers (a different type of ulcer) could be caused by psychological stress but this was proven false with the discovery of Helicobacter pylori and its role in the formation of this ulcer. Stress ulcers are a different condition and are formed by different mechanisms. The term stress ulcer is a proper medical term and should not be misinterpreted as indicating that these ulcers are caused by emotional stress. Here the term stress refers to extreme physiological changes in the body.

Another distinction between peptic and stress ulcers is their location in the upper gastrointestinal tract. Whereas ordinary peptic ulcers are found commonly in the gastric antrum and the duodenum, stress ulcers are usually found in the fundic mucosa and can be located anywhere within the stomach and proximal duodenum. Stress ulcers tend to present with multiple lesions whereas in peptic ulcers this is much more uncommon.

Signs and symptoms

Stress ulcers, as defined by overt bleeding and hemodynamic instability, decreased hemoglobin, and/or need for transfusion, were seen in 1.5% of patients in the 2252 patients in the Canadian Critical Care Trials group study. [1] People with stress ulcers have a longer ICU length of stay (up to eight days) and a higher mortality (up to four-fold) than patients who do not have stress ulceration and bleeding. [2] While the bleeding and transfusions associated with the stress ulcerations contribute to the increased mortality, the contribution of factors like low blood pressure, sepsis, and respiratory failure to the mortality independently of the stress ulceration cannot be ignored.[ citation needed ]

Risk factors

Risk factors for stress ulcer formation that have been identified are numerous and varied. However, two landmark studies and one position paper exist that addresses the topic of risk factors for stress ulcer formation:

Mechanisms

Location

The ulcerations may be superficial and confined to the mucosa, in which case they are more appropriately called erosions, or they may penetrate deeper into the submucosa. The former may cause diffuse mucosal oozing of blood, whereas the latter may erode into a submucosal vessel and produce frank hemorrhage. [3]

Lesions

The characteristic lesions may be multiple, superficial mucosal erosions similar to erosive gastroduodenitis. Occasionally, there may be a large acute ulcer in the duodenum (Curling's ulcer). [4]

Generally, there are multiple lesions located mainly in the stomach and occasionally in the duodenum. They range in depth from mere shedding of the superficial epithelium (erosion) to deeper lesions that involve the entire mucosal thickness (ulceration). [5]

Formation

The pathogenic mechanisms are similar to those of erosive gastritis. [5]

The pathogenesis of stress ulcer is unclear but probably is related to a reduction in mucosal blood flow or a breakdown in other normal mucosal defense mechanisms in conjunction with the injurious effects of acid and pepsin on the gastroduodenal mucosa. [6]

Diagnosis

Stress ulcer is suspected when there is upper gastrointestinal bleeding in the appropriate clinical setting, for example, when there is upper gastrointestinal bleeding in elderly patients in a surgical intensive care unit (ICU) with heart and lung disease, or when there is upper gastrointestinal bleeding in patients in a medical ICU who require respirators.[ citation needed ]

Stress ulcer can be diagnosed after the initial management of gastrointestinal bleeding, the diagnosis can be confirmed by upper GI endoscopy.[ citation needed ]

Prevention

The need for medications to prevent stress ulcer among those in the intensive care unit is unclear. As of 2014, the quality of the evidence is poor. [7] It is unclear which agent is best or if prevention is needed at all. [8] Benefit may only occur in those who are not being fed. [9] Possible agents include antacids, H2-receptor blockers, sucralfate, and proton pump inhibitors (PPIs). Tentative evidence supports that PPIs may be better than H2 blockers. [10]

Concerns with the use of stress ulcer prophylaxis agents include increased rates of pneumonia and Clostridium difficile colitis. [9]

Treatment

The principles of management are the same as for the chronic ulcer. [11] The steps of management are similar as in erosive gastritis. [4]

Endoscopic means of treating stress ulceration may be ineffective and operation required. [11] It is believed that shunting blood away from the mucosa makes the mucous membrane ischaemic and more susceptible to injury. [4]

Treatment of stress ulceration usually begins with prevention. Careful attention to respiratory status, acid-base balance, and treatment of other illnesses help prevent the conditions under which stress ulcers occur. Patients who develop stress ulcers typically do not secrete large quantities of gastric acid; however, acid does appear to be involved in the pathogenesis of the lesions. Thus it is reasonable either to neutralize acid or to inhibit its secretion in patients at high risk. [12]

In case of severe hemorrhagic or erosive gastritis and stress ulcers, a combination of antacids and H2-blockers may stop active bleeding and prevent bleeding from happening again. In selected patients, either endoscopic therapy or selective infusion of vasopressin into the left gastric artery may help control the hemorrhage. [13]

Epidemiology

Among those in the intensive care unit, ulceration resulting in bleeding is very rare. [9]

Related Research Articles

Peptic ulcer disease (PUD) is a break in the inner lining of the stomach, the first part of the small intestine, or sometimes the lower esophagus. An ulcer in the stomach is called a gastric ulcer, while one in the first part of the intestines is a duodenal ulcer. The most common symptoms of a duodenal ulcer are waking at night with upper abdominal pain, and upper abdominal pain that improves with eating. With a gastric ulcer, the pain may worsen with eating. The pain is often described as a burning or dull ache. Other symptoms include belching, vomiting, weight loss, or poor appetite. About a third of older people have no symptoms. Complications may include bleeding, perforation, and blockage of the stomach. Bleeding occurs in as many as 15% of cases.

<span class="mw-page-title-main">Mouth ulcer</span> Sore on the mucous membrane of the oral cavity

A mouth ulcer (aphtha) is an ulcer that occurs on the mucous membrane of the oral cavity. Mouth ulcers are very common, occurring in association with many diseases and by many different mechanisms, but usually there is no serious underlying cause. Rarely, a mouth ulcer that does not heal may be a sign of oral cancer. These ulcers may form individually or multiple ulcers may appear at once. Once formed, an ulcer may be maintained by inflammation and/or secondary infection.

<span class="mw-page-title-main">Upper gastrointestinal bleeding</span> Medical condition

Upper gastrointestinal bleeding is gastrointestinal bleeding (hemorrhage) in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit or in altered form as black stool. Depending on the amount of the blood loss, symptoms may include shock.

Hematemesis is the vomiting of blood. It can be confused with hemoptysis or epistaxis (nosebleed), which are more common. The source is generally the upper gastrointestinal tract, typically above the suspensory muscle of duodenum. It may be caused by ulcers, tumors of the stomach or esophagus, varices, prolonged and vigorous retching, gastroenteritis, ingested blood, or certain drugs.

Coffee ground vomitus refers to a particular appearance of vomit. Within organic heme molecules of red blood cells is the element iron, which oxidizes following exposure to gastric acid. This reaction causes the vomitus to look like ground coffee.

<span class="mw-page-title-main">Dieulafoy's lesion</span> Medical condition

Dieulafoy's lesion is a medical condition characterized by a large tortuous artery most commonly in the stomach wall (submucosal) that erodes and bleeds. It can present in any part of the gastrointestinal tract. It can cause gastric hemorrhage but is relatively uncommon. It is thought to cause less than 5% of all gastrointestinal bleeds in adults. It was named after French surgeon Paul Georges Dieulafoy, who described this condition in his paper "Exulceratio simplex: Leçons 1-3" in 1898. It is also called "caliber-persistent artery" or "aneurysm" of gastric vessels. However, unlike most other aneurysms, these are thought to be developmental malformations rather than degenerative changes.

<span class="mw-page-title-main">Gastrointestinal bleeding</span> Medical condition

Gastrointestinal bleeding, also called gastrointestinal hemorrhage (GIB), is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool. Small amounts of bleeding over a long time may cause iron-deficiency anemia resulting in feeling tired or heart-related chest pain. Other symptoms may include abdominal pain, shortness of breath, pale skin, or passing out. Sometimes in those with small amounts of bleeding no symptoms may be present.

<span class="mw-page-title-main">Gastritis</span> Stomach disease that is an inflammation of the lining of the stomach

Gastritis is inflammation of the lining of the stomach. It may occur as a short episode or may be of a long duration. There may be no symptoms but, when symptoms are present, the most common is upper abdominal pain. Other possible symptoms include nausea and vomiting, bloating, loss of appetite and heartburn. Complications may include stomach bleeding, stomach ulcers, and stomach tumors. When due to autoimmune problems, low red blood cells due to not enough vitamin B12 may occur, a condition known as pernicious anemia.

Curling's ulcer is an acute gastric erosion resulting as a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa. The condition was first described in 1823 and named after Thomas Blizard Curling, who observed ten such patients in 1842.

A Cushing ulcer, named after Harvey Cushing, is a gastric ulcer associated with elevated intracranial pressure. It is also called von Rokitansky–Cushing syndrome. Apart from the stomach, ulcers may also develop in the proximal duodenum and distal esophagus.

<span class="mw-page-title-main">Gastrointestinal disease</span> Medical condition

Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum, and the accessory organs of digestion, the liver, gallbladder, and pancreas.

<span class="mw-page-title-main">Sucralfate</span> Chemical compound and gastrointestinal medication

Sucralfate, sold under various brand names, is a medication used to treat stomach ulcers, gastroesophageal reflux disease (GERD), radiation proctitis, and stomach inflammation and to prevent stress ulcers. Its usefulness in people infected by H. pylori is limited. It is used by mouth and rectally.

<span class="mw-page-title-main">Gastrinoma</span> Medical condition

Gastrinomas are neuroendocrine tumors (NETs), usually located in the duodenum or pancreas, that secrete gastrin and cause a clinical syndrome known as Zollinger–Ellison syndrome (ZES). A large number of gastrinomas develop in the pancreas or duodenum, with near-equal frequency, and approximately 10% arise as primary neoplasms in lymph nodes of the pancreaticoduodenal region.

Timeline of peptic ulcer disease and <i>Helicobacter pylori</i>

This is a timeline of the events relating to the discovery that peptic ulcer disease and some cancers are caused by H. pylori. In 2005, Barry Marshall and Robin Warren were awarded the Nobel Prize in Physiology or Medicine for their discovery that peptic ulcer disease (PUD) was primarily caused by Helicobacter pylori, a bacterium with affinity for acidic environments, such as the stomach. As a result, PUD that is associated with H. pylori is currently treated with antibiotics used to eradicate the infection. For decades prior to their discovery, it was widely believed that PUD was caused by excess acid in the stomach. During this time, acid control was the primary method of treatment for PUD, to only partial success. Among other effects, it is now known that acid suppression alters the stomach milieu to make it less amenable to H. pylori infection.

Stress-related disorders constitute a category of mental disorders. They are maladaptive, biological and psychological responses to short- or long-term exposures to physical or emotional stressors. The National Institute of Environmental Health Sciences categorizes Obsessive-Compulsive Disorder (OCD) and Post-Traumatic Stress Disorder (PTSD) as stress-related disorders. However, the World Health Organization's ICD-11 excludes OCD but categories PTSD, Complex Post-Traumatic Stress Disorder (CPTSD), adjustment disorder as stress-related disorders.

<span class="mw-page-title-main">Endoclip</span>

An endoclip is a metallic mechanical device used in endoscopy in order to close two mucosal surfaces without the need for surgery and suturing. Its function is similar to a suture in gross surgical applications, as it is used to join together two disjointed surfaces, but, can be applied through the channel of an endoscope under direct visualization. Endoclips have found use in treating gastrointestinal bleeding, in preventing bleeding after therapeutic procedures such as polypectomy, and in closing gastrointestinal perforations. Many forms of endoclips exist of different shapes and sizes, including two and three prong devices, which can be administered using single use and reloadable systems, and may or may not open and close to facilitate placement.

<span class="mw-page-title-main">Ulcer</span> Index of articles associated with the same name

An ulcer is a discontinuity or break in a bodily membrane that impedes normal function of the affected organ. According to Robbins's pathology, "ulcer is the breach of the continuity of skin, epithelium or mucous membrane caused by sloughing out of inflamed necrotic tissue." Common forms of ulcers recognized in medicine include:

<span class="mw-page-title-main">Troxipide</span> Chemical compound

Troxipide is a drug used in the treatment of gastroesophageal reflux disease. Troxipide is a systemic non-antisecretory gastric cytoprotective agent with anti-ulcer, anti-inflammatory and mucus secreting properties irrespective of pH of stomach or duodenum. Troxipide is currently marketed in Japan (Aplace), China (Shuqi), South Korea (Defensa), and India (Troxip). It is used for the management of gastric ulcers, and amelioration of gastric mucosal lesions in acute gastritis and acute exacerbation of chronic gastritis.

A Cameron lesion is a linear erosion or ulceration of the mucosal folds lining the stomach where it is constricted by the thoracic diaphragm in persons with large hiatal hernias. The lesions may cause chronic blood loss resulting in iron deficiency anemia; less often they cause acute bleeding.

<span class="mw-page-title-main">Gastric folds</span>

The gastric folds are coiled sections of tissue that exist in the mucosal and submucosal layers of the stomach. They provide elasticity by allowing the stomach to expand when a bolus enters it. These folds stretch outward through the action of mechanoreceptors, which respond to the increase in pressure. This allows the stomach to expand, therefore increasing the volume of the stomach without increasing pressure. They also provide the stomach with an increased surface area for nutrient absorption during digestion. Gastric folds may be seen during esophagogastroduodenoscopy or in radiological studies.

References

  1. 1 2 Cook DJ, Fuller HD, Guyatt GH, et al. (1994). "Risk factors for gastrointestinal bleeding in critically ill patients". N Engl J Med. 330 (6): 377–81. doi: 10.1056/NEJM199402103300601 . PMID   8284001. S2CID   76019212.
  2. ↑ Cook DJ, Griffith LE, et al. (Dec 2001). "The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients". Critical Care. 5 (6): 368–75. doi:10.1186/cc1071. PMC   83859 . PMID   11737927.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  3. ↑ Manual of Gastroenterology by Gregory L. Eastwood, M.D. & Canan Avunduk, M.D., Ph.D. (1994)
  4. 1 2 3 Hai, A.A. & Shrivastava, R.B. (2003). Textbook of Surgery. Tata/McGraw-Hill. ISBN   0074621491, p. 409
  5. 1 2 Robbins Pathological Basis of Disease 6th Edition ISBN   8178670526 p. 796
  6. ↑ Manual of Gastroenterology. Gregory L. Eastwood, M.D.& Canan Avunduk, M.D., Ph.D. (1994)
  7. ↑ Krag, M; Perner, A; Wetterslev, J; Wise, MP; Hylander Møller, M (Jan 2014). "Stress ulcer prophylaxis versus placebo or no prophylaxis in critically ill patients. A systematic review of randomised clinical trials with meta-analysis and trial sequential analysis". Intensive Care Medicine. 40 (1): 11–22. doi:10.1007/s00134-013-3125-3. PMID   24141808. S2CID   24990932.
  8. ↑ Krag, M; Perner, A; Wetterslev, J; Møller, MH (Aug 2013). "Stress ulcer prophylaxis in the intensive care unit: is it indicated? A topical systematic review". Acta Anaesthesiologica Scandinavica. 57 (7): 835–47. doi:10.1111/aas.12099. PMID   23495933. S2CID   36997236.
  9. 1 2 3 Marik, PE; Vasu, T; Hirani, A; Pachinburavan, M (Nov 2010). "Stress ulcer prophylaxis in the new millennium: a systematic review and meta-analysis". Critical Care Medicine. 38 (11): 2222–8. doi:10.1097/CCM.0b013e3181f17adf. PMID   20711074. S2CID   17819100.
  10. ↑ Alhazzani, W; Alenezi, F; Jaeschke, RZ; Moayyedi, P; Cook, DJ (Mar 2013). "Proton pump inhibitors versus histamine 2 receptor antagonists for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis". Critical Care Medicine. 41 (3): 693–705. doi:10.1097/CCM.0b013e3182758734. PMID   23318494. S2CID   8138473.
  11. 1 2 Bailey & Love’s SHORT PRACTICE OF SURGERY 23rd Edition ISBN   0-340-75949-6 page 916
  12. ↑ Manual of Gastroenterology priyank sinha Gregory L. Eastwood, M.D. & Canan Avunduk, M.D., Ph.D. (1994)
  13. ↑ A Practical Approach to Emergency Medicine by Robert J. Stine, M.D., Carl R. Chudnofsky, M.D., Cynthia K. Aaron, M.D. (1994)
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