GI Stress Ulcer

DEFINITION

AKA Curling & Cushing Ulceration
- Curling are the stress type
- Cushing are the central-pathology gastrin-elevation type.
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EPIDEMIOLOGY

Seen in systemic upset
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AETIOLOGY

Up to 10% of upper GI bleeds
- occurs in eg burns (Curling's), pancreatitis, uremia, shock, CNS trauma / tumor (Cushing's)
- sepsis with SIRS
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BIOLOGICAL BEHAVIOUR

Pathophysiology (Curling)
1. Systemic hypoperfusion +/- circulating toxins
- (increased in multiple organ dysfunction syndrome (MODS))
--> decreased mucosal renewal and denuding
--> decreased perfusion leads to poorer buffering of mucosa
 2. Acid hypersecretion possible
- e.g. in burns.

Natural History
Usually develops within 2 days of a major traumatic event and is usually minimal.
Bleeding is more common in the presence of coagulopathy
Rarely perf (<10% cases)

Mainly in the parietal cell mucosa; 30% in DU, sometimes both gastric and duodenal

Pathophysiology (Cushing)
Elevated serum gastrin in context of CNS pathology.
More likely to perf.

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MANIFESTATIONS

Symptoms

GI Bleeding
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INVESTIGATIONS

Endoscopy
Confirmatory.
Majority of patients with severe trauma or burns will show erosions within 72 hrs; usually subclinical.

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MANAGEMENT

Prevention
H2 receptor agonists / omeprazole to critical ill.
Sucralfate (cryoprotective)

Medical
NG, gastric saline lavage with chilled solutions
Manage critical illness accordingly.
Reverse coagulopathy.
Omeprazole as per Upper GI Bleeding
Endoscopy
- allows diagnosis and Rx with heat probes and injections.
- angiographic injection of Left gastric or vasopressin infusion typically the next step
Surgery
- last resort
- anterior gastrotomy; nail bleeders with deep figure-of-eight sutures
- occasionally partial gastrectomy reqd
- devascularization worth considering (all but short gastrics) in a pt unstable with severe medical problems (rapid).


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REFERENCES

Doherty.
Cameron