Stress ulcers: Clinical sciences

Chapters:

Watch video only

Introduction0:00–0:52

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.

Unstable patients0:52–2:43

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 consultationAlright, now that we’re done with unstable patients, let’s go back to the ABCDE assessment and talk about stable ones.

Stable patients2:43–3:10

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.

Symptomatic patients3:10–3:59

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.
In some patients, endoscopy might show shallow, superficial erosions in the gastric mucosa. If you see this, you can diagnose superficial stress ulcers and treat the patient with either proton pump inhibitors, or PPIs for short, like pantoprazole; or histamine-2 also known as just H-2, receptor antagonists like ranitidine.

Imaging3:59–5:10

You should also monitor the labs to make sure the hemoglobin and hematocrit don’t continue to drop. On the flip side, if the endoscopy reveals deeper ulcerations, you can diagnose a deep stress ulcer.
The important thing to look out for here is active bleeding. So, if the ulcer isn’t actively bleeding, you can treat them with a PPI or an H-2 receptor antagonist, and consider endoscopic treatment of the ulcer.
Now, in some cases, endoscopy will reveal active bleeding or vessels that are visible in the ulcerated mucosa. If you see this, you should still administer a PPI or an H-2 receptor antagonist, and if endoscopic treatment fails, you may need to consult surgery or interventional radiology to perform an embolization and control the bleeding, if endoscopic treatment fails.

Asymptomatic patients5:10–7:07

Alright, now that the symptomatic patients with stress ulcers are treated, let’s talk about asymptomatic cases. As mentioned before, all ICU patients are at risk of developing stress ulcers.
So, even though history, physical, and labs don’t show signs and symptoms of stress ulcers, you need to assess these patients for important risk factors.
Let’s start with major ones. First up, there are conditions associated with bleeding, such as a history of previous GI bleeds; or a coagulopathy, which you might notice as decreased platelets or increased PT, INR, and PTT.
Additionally, the risk of developing stress ulcers is increased with some necessary interventions, such as mechanical ventilation for at least 48 hours.
Additionally, severe trauma can also lead to stress ulcers. This includes multiple trauma; burns involving at least 35 percent of the body surface area; spinal cord injury; and head injury with a Glasgow Coma Score under 10.
Lastly, other major risk factors for stress ulcers involve surgery, such as hepatic or renal transplants, and liver failure or partial resection.
Here is a clinical pearl for you! Ulcers associated with a head injury are also known as Cushing ulcers, while ulcers associated with severe burns are called Curling ulcers.
Okay, there are also minor risk factors such as ICU stay for more than 1 week; occult bleeding for at least 6 days; high-dose steroid use; and sepsis.
Here’s another clinical pearl to keep in mind! The risk of having stress ulcers is lower among patients who tolerate an oral diet, and higher in patients who have a history of H.
pylori infection, although these don’t count toward major and minor risk criteria. Alright, now that we covered all major and minor risk factors for stress ulcers, let’s see how to use this information.

Assessing risk factors for stress ulcers7:07–8:01

Now, if your patient has one or more major risk factors or two or more minor risk factors, they are considered high risk for stress ulcers.
You should treat high-risk patients with stress ulcer prophylaxis, such as PPIs like pantoprazole, or H-2 receptor antagonists like ranitidine.
You should also be alert if they develop any signs or symptoms of bleeding during their hospital stay. On the flip side, if your patient has no major risk factors or fewer than 2 minor risk factors, they are considered low risk.
In this case, you don’t need to give prophylactic medications, or may consider giving sucralfate to coat and protect the gastric mucosa, as well as giving enteral nutrition, and you should be on the lookout for any risk factors in the future.Alright, as a quick recap… Patients in the ICU are exposed to stressors that may lead to stress ulcer development.

Review8:01–9:11

Unstable patients require an upper endoscopy to diagnose the ulcer, and possibly surgical or interventional radiology consultation to treat it.
When it comes to symptomatic stable patients, they also require an upper endoscopy to diagnose the ulcer. Shallow ulcers are treated with PPIs or H-2 receptor antagonists.
On the other hand, deep ulcers should be assessed for bleeding. If there is no bleeding, the treatment involves PPIs or H-2 receptor antagonists, and possible endoscopic treatment.
If the deep ulcer is bleeding, you can start PPIs or H-2 receptor antagonists, but you also need to consult surgery or interventional radiology for possible embolization.
Finally, you need to assess asymptomatic ICU patients for stress ulcer risk factors. If they are high-risk, start them on PPIs or H-2 receptor antagonists.
However, if they are low-risk,
Stress ulcers: Video, Causes, and Symptoms | Osmosis