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STRESS ULCERATION Introduction Psychological stress may cause ordinary peptic disease but stress ulcer is different. Q. What is Stress ulcer? A single or multiple fundic mucosal ulcers which often gives upper gastrointestinal bleeding developed during the severe physiologic stress of serious illness. see also psychological stress (medicine) for more details. Q.Ordinary peptic ulcers and Stress ulcers? Ordinary peptic ulcers are found commonly in the “gastric antrum and the duodenum” whereas Stress ulcers are found commonly in “fundic mucosa and can be located anywhere within the stomach and proximal duodenum”. see also peptic ulcer {Link without Title} for more details. see also Timeline Of Peptic Ulcer Disease And Helicobacter Pylori for more details. Q. Who can get Stress ulcers?
Example:
It is possible that poor mucosal oxygenation, differences in acid-base balance, and elevated circulating corticosteroids may contribute to the formation of these ulcers. Manual of Gastroenterology by Gregory L. Eastwood, M.D. & Canan Avunduk, M.D.,Ph.D.(1994) Diagnosis Q. When is stress ulcer suspected?
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Q. How stress ulcer can be diagnosed?
The site of ulcerations The ulcerations may be superficial and confined to the mucosa, in which case they are more appropriately called erosions, or they may penetrate deeper into the submucosa. The former may cause diffuse mucosal oozing of blood, whereas the latter may erode into a submucosal vessel and produce frank hemorrhage. Manual of Gastroenterology by Gregory L. Eastwood, M.D. &Canan Avunduk, M.D., Ph.D.(1994) Lesion of stress ulcers
Stress Ulcer formation The pathogenic mechanisms are similar to those of erosive gastritis.” Robbins PATHOLOGIC BASIS OF DISEASE 6TH Edition ISBN 81-7867-052-6 page 796 Q. How and why Stress ulcer is developed? The pathogenesis of stress ulcer is unclear but probably is related to a reduction in mucosal blood flow or a breakdown in other normal mucosal defense mechanisms in conjunction with the injurious effects of acid and pepsin on the gastroduodenal mucosa. Manual of Gastroenterology Gregory L. Eastwood, M.D.& Canan Avunduk, M.D., Ph.D.(1994) Prophylaxis Prevention of this condition is far better than trying to treat it once it occurs. Bailey & Love’s SHORT PRACTICE OF SURGERY 23rd Edition ISBN 0 340 75949 6 page 916 Q. How to prevent it's development? In recent years by using Ranitidine (H2-receptor antagonist) and nasogastric administration of sucralfate has reduced the incidence of stress ulceration . Management The principles of management are the same as for the chronic ulcer. Bailey & Love’s SHORT PRACTICE OF SURGERY 23rd Edition ISBN 0 340 75949 6 page 916 The steps of management are similar as in erosive gastritis.TEXTBOOK OF SURGERY ISBN 0-07-4621-149-1 page 409 Treatment Endoscopic means of treating stress ulceration may be ineffective and operation required. Bailey & Love’s SHORT PRACTICE OF SURGERY 23rd Edition ISBN 0 340 75949 6 page 916 It is believed that shunting of blood away from the mucosa makes the mucous membrane ischaemic and more susceptible to injury. TEXTBOOK OF SURGERY ISBN 0-07-4621-149-1 page 409 Treatment of stress ulceration usually begins with prevention. Careful attention to respiratory status, acid-base balance, and treatment of other illnesses helps prevent the conditions under which stress ulcers occur. Patients who develop stress ulcers typically do not secrete large quantities of gastric acid; however, acid does appear to be involved in the pathogenesis of the lesions. Thus it is reasonable either to neutralize acid or to inhibit its secretion in patients at high risk. Manual of Gastroenterology Gregory L. Eastwood, M.D. & Canan Avunduk, M.D., Ph.D.(1994) In case of severe hemorrhagic or erosive gastritis and stress ulcers, a combination of antacids and H2-blockers may stop active bleeding and prevent re bleeding. In selected patients, either endoscopic therapy or selective infusion of vasopressin into the left gastric artery may help control the hemorrhage. A Practical Approach to Emergency Medicine by Robert J. Stine, M.D., Carl R. Chudnofsky, M.D., Cynthia K. Aaron, M.D. (1994) FOOTNOTE Citation templates
SELECTED READINGS Cheung, L. Y. Pathogenesis, prophylaxis and treatment of stress gastritis. Am. J. Surg. 156:437, 1988. Craven, D. E., et al. Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation. Am. Rev. Respir. Dis. 133:792, 1986. Driks, M. R., et al. Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers. N. Engl. J. Med. 317:1376, 1987. DuMoulin, G. C., et al. Aspiration of gastric bacteria in antacid-treated patients: A frequent cause of postoperative colonisation of the airway. Lancet 1:242, 1982. Lamothe, P. H., et al. Comparative efficacy of cimetidine, famotidine, ranitidine, and Mylanta in postoperative stress ulcers: Gastric pH control and ulcer prevention in patients undergoing coronary artery bypass graft surgery. Gastroenterology 100:1515, 1991. Priebe, H. J., et al. Antacid versus cimetidine in preventing acute gastrointestinal bleeding: A randomized trial in 75 ill patients. N. Engl. J. Med. 302:426, 1980. Shuman, R. B., Schuster, D. P., and Zuckerman, G. R. Prophylactic therapy for stress ulcer bleeding: A reappraisal. Ann Intern. Med. 106:562, 1987. Tryba, M. Stress bleeding prophylaxis with sucralfate: Pathophysiologic basis and clinical use. Scand. J. Gastroenterol. 173 25:22, 1990. |
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