Stress ulcers

• Stress-related erosive syndrome
  • Presence of multiple superficial erosions of the gastric mucosa
  • Beginning in the proximal acid-secreting portion of the stomach and progressing distally
• Cushing’s ulcers
  • Develop following central nervous system injury.
  • Tend to be single and deep and may involve the esophagus, stomach, or duodenum
• Curling’s ulcers
  • Occur following burns involving greater than 30 percent total body surface area.
  • Curling’s ulcers can occur in the stomach or duodenum
• Stress gastritis
  • Erosions occur after physical trauma, shock, hemorrhage, and sepsis.
    • Thus, stress gastritis represents end-organ failure of the stomach in critical illness.
  • Can be identified within hours following injury and occur nearly universally (in the absence of prophylaxis) following severe shock

Management

Medical management

• as pre normal treatment

Endoscopic management

• As per normal treatment
• Often difficult as diffuse nature of stress ulcers

Surgical approach

• In the case of severe bleeding with inability to control medically or endoscopically or in a unstable patient
• This is typically a difficult situation given the underlying reason a patient has leading to the development of stress ulcers
  • Poor prognosis mortality rates ranging from 30 to 70 percent in patients with complicated disease
  • Those who require surgical intervention have mortality rates in excess of 50 percent. Much of the morbidity and mortality are attributed to the patient’s underlying disease processes.
• Approach
  • Long gastrotomy high on the anterior wall of the stomach in order to identify and oversew all bleeders
  • A truncal vagotomy with pyloroplasty can be added if the patient’s condition permits. Gastric resection and devascularization procedures are rarely performed and are usually reserved for reoperations for stress ulcer bleeding or for patients who present with a gastric perforation