Curling Ulcer

A stress-related erosion or ulcer of the stomach or duodenum (classically the duodenum and proximal stomach) that complicates severe burns, usually burns of more than 30 to 35% of total body surface area.

• Incidence was up to 25% of major burns in the past, with life-threatening bleeding in about 5 to 10%; with early resuscitation, early enteral feeding and acid suppression it is now under 5%.
• Risk factors: burn size and depth, inhalational injury, mechanical ventilation for more than 48 hours, sepsis, shock, coagulopathy, renal failure, and previous peptic ulcer; it appears within 3 to 10 days of injury.
• Mechanism: hypovolaemia and splanchnic vasoconstriction cause mucosal ischaemia, with reperfusion injury, reduced mucus and bicarbonate, back diffusion of acid, and a systemic inflammatory response.

Usually silent until bleeding: coffee-ground nasogastric aspirate, haematemesis, melaena, falling haemoglobin, hypotension, tachycardia.

• Perforation: sudden abdominal distension, peritonitis, free air (masked by sedation and burns pain).
• Differential diagnosis: peptic ulcer, Mallory-Weiss tear, oesophagitis, erosive gastritis, varices, ischaemic bowel, acalculous cholecystitis, pancreatitis, coagulopathy-related bleeding.
• Complications: haemorrhage with shock, perforation, increased transfusion requirement, longer intensive care stay, and death (mortality with bleeding is about 30 to 50%, mainly from the burn).

Clinical diagnosis when bleeding occurs in a burn patient: coffee-ground aspirate of more than 100 mL, haemoglobin fall of 20 g/L or more, melaena or transfusion requirement.

• Upper endoscopy when stable: multiple superficial erosions or ulcers, mainly in the fundus and body of the stomach and proximal duodenum, with oozing.
• Blood tests: full blood count, clotting profile, fibrinogen, urea, creatinine, electrolytes, liver tests, lactate, group and crossmatch.
• Erect chest X-ray or CT for perforation; CT angiography or angiography for brisk bleeding when endoscopy does not show the source.

Burn resuscitation (prevents ischaemia): lactated Ringer solution 2 to 4 mL/kg per % total body surface area burned over 24 hours (half in the first 8 hours from injury), titrated to urine output of 0.5 mL/kg/hour in adults (1 mL/kg/hour in children weighing under 30 kg), with albumin 5% added after 8 to 12 hours for large burns.

• Early enteral feeding within 6 to 24 hours (30 to 35 kcal/kg/day with 1.5 to 2 g/kg/day of protein) through a nasogastric or nasojejunal tube, which protects the mucosa.
• Prophylaxis for all patients with major burns:
  • Pantoprazole 40 mg IV once daily (or omeprazole 40 mg IV or enterally daily) until burns are healing, the patient is on full enteral feeding and risk factors have resolved.
  • Famotidine 20 mg IV twice daily (10 mg twice daily if creatinine clearance is under 50 mL/min) is an alternative, with less effect.
  • Sucralfate 1 g four times daily by nasogastric tube is an alternative (separate from other drugs by 2 hours; avoid in renal failure).
• Treatment of bleeding:
  • Resuscitate with crystalloid and red cells at a haemoglobin of 70 g/L (80 g/L in cardiovascular disease); correct coagulopathy (platelets to 50 x 10^9/L or more, vitamin K 10 mg IV, prothrombin complex concentrate 25 to 50 units/kg for warfarin, fresh frozen plasma 10 to 15 mL/kg, cryoprecipitate for fibrinogen under 1.5 g/L).
  • Omeprazole 80 mg IV bolus then 8 mg/hour for 72 hours.
  • Endoscopy within 24 hours: adrenaline 1 in 10,000 (up to 10 mL) injection with a thermal probe or haemoclip for focal bleeding; diffuse erosive oozing responds to acid suppression and correction of coagulopathy.
  • Angiographic embolisation for ongoing bleeding; surgery (oversewing or resection) is rarely needed.
  • Tranexamic acid is not helpful.
• Perforation: laparotomy with repair or omental patch, broad-spectrum antibiotics (piperacillin-tazobactam 4.5 g IV every 6 hours).
• Treat the burn: wound excision and grafting, sepsis control, analgesia (morphine 0.05 to 0.1 mg/kg IV as needed), thromboprophylaxis with enoxaparin 40 mg SC daily (20 mg if creatinine clearance is under 30 mL/min).
• Helicobacter pylori testing and treatment after recovery when positive (omeprazole 20 mg twice daily, amoxicillin 1 g twice daily and clarithromycin 500 mg twice daily for 14 days).
• Special groups: children (famotidine 0.25 mg/kg IV every 12 hours, maximum 20 mg, or omeprazole 1 mg/kg once daily, maximum 40 mg; Parkland-type fluid of 3 to 4 mL/kg per % burn plus maintenance fluid); pregnancy (omeprazole 20 to 40 mg daily or famotidine 20 mg twice daily, early burns centre care, fetal monitoring); elderly (lower fluid volumes cautiously, famotidine confusion risk); renal impairment (reduce famotidine, avoid sucralfate and aluminium antacids); inhalational injury (prophylaxis from admission).
• Red flags: haematemesis, haemoglobin fall of 20 g/L or more, shock, abdominal rigidity, free air, coagulopathy, transfusion needs.
• Follow-up: stop prophylaxis when burns are healing, feeding is established and the patient is off ventilation; continue omeprazole 20 to 40 mg daily for 4 to 8 weeks after a bleed; check haemoglobin and ferritin at discharge and at 4 to 8 weeks; repeat endoscopy at 6 to 8 weeks for gastric ulcers.