Stress Ulcer

Acute gastric and duodenal mucosal erosions and ulcers that arise during severe physiological stress (critical illness, major surgery, burns, trauma, head injury), also called stress-related mucosal disease; the stomach corpus and fundus are most often affected.

• Risk factors: mechanical ventilation for more than 48 hours, coagulopathy (platelets less than 50 x 10^9/L, INR more than 1.5), shock, sepsis, acute kidney injury, burns involving more than 35% of body surface area, major head or spinal injury, multiple trauma, liver failure, and high-dose corticosteroids with NSAIDs.
• Clinically important bleeding (haemodynamic instability, transfusion) occurs in about 1 to 4% of critically ill patients without prophylaxis, and overt bleeding in up to 5 to 15%; mortality is higher in those who bleed (about 30 to 50%, mainly due to the underlying illness).
• Mechanism: splanchnic hypoperfusion and ischaemia-reperfusion injury, reduced mucosal prostaglandins and bicarbonate, and acid back-diffusion cause mucosal necrosis; increased intracranial pressure may raise vagal acid secretion.

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

• Perforation is uncommon; sudden abdominal signs or free air in a sedated patient.
• Examination is limited in sedated patients; nasogastric aspirate, abdominal distension and rectal examination help.
• Differential diagnosis: peptic ulcer (pre-existing), Mallory-Weiss tear, oesophagitis, varices and portal hypertensive gastropathy, Dieulafoy lesion, gastric antral vascular ectasia, coagulopathy-related bleeding, ischaemic bowel, nasogastric tube trauma.
• Complications: haemorrhage with shock, transfusion requirement, perforation, increased length of intensive care stay, and death; adverse effects of prophylaxis (pneumonia, Clostridioides difficile infection).

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

• Upper endoscopy when stable: multiple superficial erosions or ulcers, usually in the corpus and fundus, with oozing; look for a focal ulcer or varices.
• Blood tests: full blood count, clotting profile, fibrinogen, urea and creatinine, liver tests, lactate, group and crossmatch; correct coagulopathy.
• Exclude other causes: CT angiography or angiography for brisk bleeding with a non-diagnostic endoscopy; erect chest X-ray or CT for perforation.
• Check ventilator status, enteral feeding, drugs (anticoagulants, antiplatelets, corticosteroids, NSAIDs).

Prophylaxis for patients with a major risk factor (ventilation for more than 48 hours, coagulopathy, shock with organ failure, major burns, head injury, or two or more minor risks):

• Pantoprazole 40 mg IV once daily (or omeprazole 40 mg IV or enterally daily, esomeprazole 40 mg daily); stop when the patient is off ventilation and eating and the risk factors have resolved.
• Famotidine 20 mg IV twice daily (10 mg twice daily if creatinine clearance is below 50 mL/min; mental confusion can occur) is an alternative with less effect.
• Sucralfate 1 g four times daily by nasogastric tube is an alternative (give separately from other drugs by 2 hours; avoid in renal failure because of aluminium and with enteral feeding blockage risk).
• Early enteral feeding (started within 24 to 48 hours) reduces risk and is encouraged; avoid prophylaxis in low-risk patients because it raises pneumonia and Clostridioides difficile infection.

```{=html} <!-- --> ``` - Treatment of bleeding:

• Resuscitate with two large-bore cannulae, 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 or INR above 1.5, fresh frozen plasma 10 to 15 mL/kg, cryoprecipitate for fibrinogen less than 1.5 g/L); hold anticoagulants and antiplatelets when possible.
  • Omeprazole 80 mg IV bolus then 8 mg/hour for 72 hours (or pantoprazole 80 mg bolus then 8 mg/hour).
  • Endoscopy within 24 hours when stable: adrenaline 1 in 10,000 injection (up to 10 mL) with a thermal probe or haemoclip for a focal bleeding lesion; diffuse erosive oozing is treated with acid suppression, correction of coagulopathy and sometimes topical haemostatic powder.
  • Angiographic embolisation for ongoing bleeding when endoscopy fails; surgery (oversewing, vagotomy and pyloroplasty, or gastrectomy) as a last resort with high mortality.
  • Tranexamic acid is not helpful.
• Treat the cause of stress: restore perfusion (maintain mean arterial pressure of 65 mmHg or more), treat sepsis, wean ventilation, correct hypoxaemia and acidosis.
• Avoid ulcerogenic drugs (NSAIDs, high-dose corticosteroids) when possible.
• Helicobacter pylori testing and eradication after recovery when positive (omeprazole 20 mg twice daily, amoxicillin 1 g twice daily and clarithromycin 500 mg twice daily for 14 days, or omeprazole 20 mg twice daily, bismuth subsalicylate 524 mg four times daily, tetracycline 500 mg four times daily and metronidazole 500 mg three to four times daily for 14 days).
• Special groups: children (famotidine 0.25 mg/kg IV every 12 hours (maximum 20 mg) or omeprazole 1 mg/kg IV or enterally once daily, maximum 40 mg, for ventilated or coagulopathic patients); pregnancy and peripartum (omeprazole 20 to 40 mg daily or famotidine 20 mg twice daily if risk factors; avoid sucralfate in renal disease); elderly (famotidine dose reduction, delirium risk with H2 blockers); renal impairment (reduce famotidine; avoid sucralfate and aluminium antacids); burns (prophylaxis from admission, enteral nutrition early); liver disease (check for varices and portal hypertensive gastropathy).
• Red flags: haematemesis, haemoglobin fall of 20 g/L or more, haemodynamic instability, free air, transfusion needs, ongoing bleeding after endoscopy, thrombocytopenia or coagulopathy.
• Follow-up: stop prophylaxis when risk resolves (within 24 to 48 hours of extubation and feeding); continue oral 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; review the indication for any proton pump inhibitor at discharge to avoid unnecessary long-term use.