What is Stress Ulcer?
Stress ulcer is defined as lesions or erosion on the mucous membrane of the stomach lining which often occurs at the gastric fundus. The erosion can appear superficial and contained in the mucosa which can cause bleeding in the mucosal. The lesion can also penetrate deeper into the submucosa that may cause hemorrhage. The condition of stress ulcer may become complicated with upper gastrointestinal bleeding.
Stress ulcer is common to critically ill patient with a higher mortality rate as compared to those who do not suffer from stress ulcer. Patients who have been in mechanical vent for more than 48 hours are also at high risk for stress ulcer. Patients in respiratory distress and coagulopathy are the most at high risk for stress ulcer.
Stress Ulcer Types
There are two main types of stress ulcer each defined according to the location of lesion or erosion and these are:
- Cushing’s Ulcer – lesion is located in the lining of the stomach but may also appear in the proximal part of the duodenum and the distal esophagus although the occurrence is rare. Cushing’s syndrome is mainly due to elevated intracranial pressure as a result of vagal nuclei stimulation causing gastric acid secretion in elevated level.
- Curling’s Ulcer – a stress ulcer commonly found in severely burned patient as complication. The lesion can be found in the duodenum. The ulcer is the result of decreased plasma volume resulting to sloughing of gastric mucosa.
Stress Ulcer Symptoms
Stress ulcer is asymptomatic during the early stage but as the ulcer progresses the symptom is similar to that of peptic ulcer such as burning pain in the stomach which comes and goes, nausea, vomiting, loss of appetite and blood in excreted waste products. In peptic ulcer, symptom may be easily alleviated through eating while it does not ease the pain in stress ulcer.
It is important that medical health team should monitor closely critically ill patient as the present condition of the patient puts them in no position to neither protect nor complain verbally from symptoms of stress ulcer.
Stress Ulcer Causes
The incidence of stress ulcer occurrence to critically ill patient has been unknown although it has been related to ischemic injury of the gastric mucosa, cytoprotectant being lost and the gastric acid assaulting the gastric mucosa.
Ischemia described as insufficiency in the blood flow, is said to be the main culprit for stress ulcer in severely ill patient as the gastrointestinal system has reduced blood flow due to debilitating state of the patient thereby diminishing demand for oxygen supply. The injured mucosa has the inability to repair itself and therefore cannot protect the mucosa from aggressive factors such as gastric acid, bile and digestive enzymes.
Stress ulcer is also pin pointed to bacterial infection of the gastrointestinal system specifically of H. pylori bacteria. The critical stage of the patient exposed them to low resistance thereby bacterial infection is highly anticipated.
The occurrence of stress ulcer is however common to patient with the following condition:
- Severely burned patient
- Patient under mechanical ventilation of more than 48 hours
- Patient with intracranial pressure accompanied by coma
- Severe trauma
- ICU patients with complications such as: Coagulopathy, Shock and Jaundice
- Patient who underwent abdominal, cardiovascular and thoracic surgery
Stress Ulcer Treatment
Preventing stress ulcer from occurring is better than treating as debilitating state of patient has the inability to clearly express symptoms of stress ulcer. Stress ulcer prophylaxis is given to patient who is at high risk for developing this type of ulcer. Prophylaxis medications given are:
- Antacids – given to patient who is high risk for hemorrhage due to bleeding
- H2 Receptors Antagonist – widely use to critically ill patient as it is known to be effective in prevent stress ulcer from forming.
- Proton Pump Inhibitors – widely use due to effects where patient have neither episode of bleeding nor signs of toxicity.
The aim of treating and managing stress ulcer is neutralizing acid or inhibiting acid secretion to patient who is high risk for stress ulcer. It is important to maintain balance of gastric pH to >3.5. Acid suppression treatment brought a remarkable decrease of bleeding as a result of stress ulcer making it the choice in treating the condition.
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