Stress ulcers: Clinical sciences

Stress ulcers are erosions or ulcerations in the upper GI tract caused by the effects of stressors such as hypovolemia, shock, sepsis, and trauma, as well as excessive stimulation of parietal cells by gastrin. They are also known as stress-induced gastropathy, stress-induced gastritis, or stress-related mucosal damage.

Stress ulcers usually develop in the stomach fundus and body within hours of major trauma or serious illness; or in the distal antrum and duodenum after several days in the hospital. Stress ulcers are more common in patients admitted to the ICU since they are more likely to experience stressors that injure the mucosal barrier. Based on their appearance, stress ulcers can be shallow or deep.

When assessing an ICU patient with signs and symptoms suggestive of stress ulcers, you should first determine if your patient is unstable or stable by doing an ABCDE assessment. If the patient is unstable, start acute management to stabilize the airway, breathing, and circulation. This means that you might need to intubate the patient to establish or maintain the airway, provide supplemental oxygen, obtain IV access, administer fluids and electrolytes, and sometimes place a nasogastric tube for gastric lavage, or even transfuse blood products before continuing with your assessment.

After you complete the acute management, obtain a focused history and physical, and order labs like CBC, and coagulation studies such as PT, PTT, and INR. The history might reveal hematemesis, as well as the presence of frank blood or coffee-ground emesis in the nasogastric aspirate. Additionally, some patients might have melena. On physical exam, you might find signs of hemodynamic instability like tachycardia and hypotension, as well as signs of bleeding like blood on rectal exam.

When it comes to labs, they usually reveal signs of severe bleeding like low hemoglobin and hematocrit levels, or levels that have decreased since admission; as well as signs of coagulopathy like low platelets or increased PT, PTT, and INR. Now, if you see any signs and symptoms that point to bleeding in ICU patients, suspect stress ulcers and proceed with an upper endoscopy. If the endoscopy demonstrates active bleeding in these patients, you should think of a stress ulcer and perform endoscopic bleeding control. Lastly, you may obtain surgical or interventional radiology consultation

Alright, now that we’re done with unstable patients, let’s go back to the ABCDE assessment and talk about stable ones. When it comes to stable ICU patients, your first step is to obtain a focused history and physical examination, as well as labs like CBC; coagulation studies, such as PT, PTT, and INR; and a fecal occult blood test.

Now, let’s go over symptomatic cases. An ICU patient with stress ulcers typically presents with hematemesis, or frank blood or coffee ground emesis in their nasogastric aspirate; and anemia. Sometimes, patients will have melena as well. On the physical exam, you might find tachycardia, and blood on rectal exam. Finally, labs might reveal low hemoglobin and hematocrit levels, or levels that have decreased since admission; increased PT, PTT, and INR; or a positive fecal occult blood test. Just like before, if you see signs and symptoms of bleeding in ICU patients, suspect stress ulcers and proceed with an upper endoscopy.