What is stress ulcer
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Here is a complete overview of stress ulcers based on authoritative surgical textbooks:
Stress Ulcer
Definition
A stress ulcer (also called stress gastritis or acute stress ulceration) is an acute mucosal injury of the stomach - and less commonly the duodenum - that occurs in critically ill or severely injured patients. The lesions are typically multiple, shallow erosions in the proximal (acid-secreting) stomach, occurring in the setting of major physiologic stress.
Pathophysiology
The core mechanism is a mismatch between mucosal defense and acid injury, driven by:
- Splanchnic hypoperfusion and mucosal ischemia - the GI mucosa is highly sensitive to hemodynamic compromise
- Reperfusion injury after resuscitation from shock
- Decreased mucosal protection (reduced mucus and bicarbonate secretion)
- Continued gastric acid secretion in the setting of an impaired mucosal barrier
Mechanical ventilation using high PEEP or high tidal volumes can worsen this by increasing intrathoracic pressure, decreasing venous return, and reducing cardiac output, thereby worsening splanchnic perfusion.
- Sabiston Textbook of Surgery, p. 941
- Maingot's Abdominal Operations, p. 476
Named Special Forms
| Eponym | Setting |
|---|---|
| Curling ulcer | Major burns (>35% TBSA) |
| Cushing ulcer | CNS injury / intracranial hypertension |
Risk Factors
The two most important independent risk factors (by multiple regression analysis) are:
- Mechanical ventilation >48 hours
- Coagulopathy (platelets <50,000/mm³, INR >1.5, or PTT >2x control)
Patients with both risk factors have a 3.7% rate of clinically significant bleeding, vs. only 0.1% in those with neither.
Other risk factors include:
-
Hypotension / sepsis
-
Respiratory failure
-
Hepatic or renal failure
-
Corticosteroid use
-
Spinal cord injury
-
Age >55 years
-
Injury Severity Score >16
-
Emergency surgery / reoperation
-
Maingot's Abdominal Operations, p. 476
Incidence
- Endoscopically, gastric erosions are detectable in up to 90-100% of critically ill patients within 24 hours of major insult
- However, clinically significant hemorrhage (requiring transfusion, causing hypotension) occurs in only 0.4-5%
- In large modern series (>28,000 patients), the rate of clinically significant stress ulceration is approximately 0.4%, and overt stress bleeding as low as 0.1%, reflecting improvements in ICU care
Diagnosis
- Endoscopy is the gold standard - lesions appear as multiple shallow areas of erythema, friability, and focal hemorrhage, visible as early as 12 hours after the insult
- Histology: coagulation necrosis of superficial endothelium, leukocyte infiltration into the lamina propria; notably, no signs of chronicity (no fibrosis or scarring)
- Barium contrast has no role - it delays and interferes with endoscopy
- Important to distinguish from other bleeding sources: duodenal ulcer (26%), gastric ulcer (13%), esophagitis (18%), varices (7%) are also common in postoperative patients
Prophylaxis
Indications for prophylaxis are primarily patients with:
- Mechanical ventilation >48 hours
- Coagulopathy
- Neurotrauma / raised ICP
- New use of high-dose steroids or NSAIDs
- History of prior GI bleed
Agents used:
| Class | Examples |
|---|---|
| Proton pump inhibitors (PPIs) | Pantoprazole, omeprazole |
| H2-receptor antagonists | Ranitidine, famotidine, cimetidine |
| Mucosal protective agents | Sucralfate |
PPIs show a lower rate of clinically important upper GI bleeding compared to H2-blockers, though no difference in mortality or C. difficile infection was found in a major RCT.
Caution: Gastric acid suppression removes a natural barrier against pathogens, and is associated with gastric bacterial overgrowth, aspiration pneumonia, and Clostridioides difficile survival.
Early enteral nutrition is increasingly recognized as an important mucosal-protective strategy, reducing the need for pharmacologic prophylaxis.
- Sabiston Textbook of Surgery, p. 941
- Maingot's Abdominal Operations, p. 476
Treatment of Active Bleeding
- Endoscopic intervention is first-line for active hemorrhage
- Failure of prophylaxis (bright red blood via nasogastric tube): addition of a second agent from a different therapeutic class is the preferred approach
- Surgical intervention (vagotomy, oversewing, partial gastrectomy) is reserved for refractory cases
Key Takeaway
Stress ulcers are common endoscopic findings in the ICU but rarely cause life-threatening bleeding in modern critical care. The high-risk groups are those on prolonged mechanical ventilation and those with coagulopathy. Early enteral feeding and targeted acid suppression are the mainstays of prevention.
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