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  • • Physiologically stressful illness

    • Upper GI bleeding

    • Acute gastric or duodenal ulcers

    • 4 major etiologic factors

    • 1. Shock

      2. Sepsis

      3. Burns (Curling ulcers)

      4. CNS tumors or trauma (Cushing ulcers)

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Epidemiology

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  • • Clinically apparent ulcers develop in about 20% of susceptible patients

    • Perforation occurs in 10% of cases

    • Most stress ulcers develop in the stomach; 30% in the duodenum; sometimes both are involved

    • Decreased mucosal resistance is the first step, which may involve the effects of ischemia and circulating toxins, followed by decreased mucosal renewal, decreased production of endogenous prostanoids, and thinning of the surface mucus layer

    • Acute ulcers associated with CNS tumors or injuries differ from other stress ulcers with elevated serum gastrin and gastric acid secretion

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Symptoms and Signs

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  • • Hemorrhage is nearly always the first manifestation

    • Pain rare

    • Physical exam is not contributory except to reveal gross or occult fecal blood or signs of shock

    • Clinically evident bleeding is usually seen 3-5 days after the injury, and massive bleeding generally does not appear until 4-5 days later

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Laboratory Findings

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  • • Anemia

    • Elevated gastrin and gastric acid secretion with Cushing ulcers

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Imaging Findings

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  • Gastroduodenal endoscopy: Shows shallow, discreet ulcers in the stomach, duodenum, or both

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  • • Any patient with recent history of shock, sepsis, burns, or CNS tumors or trauma and upper GI bleeding should undergo gastroduodenal endoscopy to evaluate for stress ulcers

    • All patients at risk for stress ulcers should receive pharmacologic ulcer prophylaxis

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Rule Out

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  • • Other causes of GI hemorrhage

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  • • Evidence of GI bleeding

    • -NG aspiration of blood confirms upper GI source

    • Endoscopy to confirm bleeding ulcer as source

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When to Admit

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  • • Patients with antecedent physiologic stress necessary for development of stress ulcer will already be hospitalized

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Surgery

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  • • Gastric lavage

    • Endoscopic treatment of bleeding ulcers

    • Suture the bleeding points, vagotomy, and antrectomy or pyloroplasty

    • Rarely, total gastrectomy is necessary

    • Infusion of vasopressin into the left gastric artery through a percutaneously placed catheter may be useful

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Indications

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  • • Failure of nonoperative treatment

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Medications

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  • • H2-receptor blockers may decrease the rate of rebleeding

    • Blood and/or crystalloid infusion as indicated

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Treatment Monitoring

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  • • Monitor clinical signs of ongoing bleeding, such as bloody NG aspirate and decreasing Hct

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Complications

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  • • Rebleeding

    • Perforation

    • Obstruction

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Prognosis

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  • • Overall mortality determined largely by underlying disease

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Prevention

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  • • H2-receptor antagonists or sulcrate given prophylactically to critically ill patients

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