General Medical Information

Stress Ulcers

David M. Barrs

In patients who do not have a history of peptic ulcer disease, the most common cause of postoperative upper gastrointestinal bleeding is stress ulceration of the gastric mucosa. These ulcers develop as a result of trauma, surgery, or the stress associated with severe illness. The ulcers are usually painless, and the clinical presentation may be limited to a bloody aspirate from an indwelling nasogastric tube, melena, or an unexplained fall in hematocrit. The most reliable method of diagnosis is gastric endoscopy to visualize the shallow ulcerations, which are usually confined to the proximal part of the stomach.

The main thrust of management should be prevention, and prophylactic measures should be considered in all major head and neck cases. Prevention of stress ulceration is aimed at reducing gastric acidity (above pH of 4 to 5), which may be accomplished by antacids or histamine-receptor blockers, such as cimetidine or ranitidine. The i.v. dose of cimetidine is 50 mg/h or 300 mg every 6 hours, and the dose for ranitidine is 6.25 mg/h or 50 mg every 8 hours for the continuous or bolus injections, respectively. A continuous i.v. infusion is more effective than bolus injections. Cytoprotective agents, such as sucralfate suspension, maintain the integrity of the stomach mucosal barrier. The dose is 1 g in 10 to 20 mL of sterile water infused into the stomach every 6 to 8 hours via nasogastric tube.

If stress ulcers develop, treatment methods are similar to those used in prophylaxis. Emergencies (e.g., hypovolemia) must be managed immediately with fluid or blood replacement. For massive bleeding, a large-bore nasogastric tube is placed to decompress the stomach, monitor gastric pH, and provide access for antacid therapy and cooled saline irrigations. Intravenous cimetidine or ranitidine is given. Angiography with selective injection of vasopressin has been used. Arterial embolization or gastric endoscopy with electrocauterization or laser photocoagulation may be attempted. Surgical intervention may be necessary in patients with persistent bleeding or ulceration despite conservative therapy.