II. Causes

  1. See Peptic Ulcer Disease
  2. Medications
    1. Aspirin
    2. NSAIDs
    3. Alcohol
  3. Severe stress (mucosal protection breaks down, allows for splanchnic hypoperfusion)
    1. Burns
    2. Sepsis
    3. Trauma
    4. Surgery
    5. Shock
    6. Respiratory Failure
    7. Renal Failure
    8. Liver failure
    9. Mechanical Ventilation

III. Symptoms (May be asymptomatic)

  1. Epigastric discomfort
  2. Nausea or Vomiting
  3. Hematemesis
  4. Melena

IV. Signs

  1. See Peptic Ulcer Disease
  2. Epigastric tenderness

V. Diagnosis

  1. Upper endoscopy (EGD)
    1. Mucosal inflammation and engorgement
    2. Erosions and Hemorrhages
  2. Upper GI barium study
    1. Thickened rugae

VII. Prevention: GI Prophylaxis in Outpatients on Antiplatelet Agents or Anticoagulants (Gastroprotection)

  1. Indications: Antiplatelet Agents or Anticoagulants (Aspirin, Apixaban, Warfarin) AND
    1. Second Antiplatelet or Anticoagulant
    2. Prior upper gastrointestinal bleed
    3. Higher dose Corticosteroids (lower doses may not require prophylaxis)
    4. NSAIDs
  2. Approach
    1. Proton Pump Inhibitor or H2 Blocker
    2. Stop GI prophylaxis when Anticoagulants or antiplatelet agents are discontinued
    3. Reevaluate indications for Anticoagulant and antiplatelet agents at routine clinic visits
    4. Eliminate other causes of peptic ulcer (e.g. Alcohol, NSAIDS, Tobacco)
  3. Precautions
    1. Continuous acid suppression (esp. Proton Pump Inhibitor) carries many risks including Clostridium difficile

VIII. Prevention: GI Prophylaxis in Critically Ill Hospitalized Patients (ICU)

  1. Indications: High risk patients in ICU
    1. Mechanical Ventilation
    2. Coagulopathy
    3. Multiple Traumatic injuries
    4. Recent Gastrointestinal Bleeding
    5. High dose Corticosteroids (equivalent to Prednisone 60 mg/day)
  2. Protocol
    1. Start GI prophylaxis in high risk ICU patients
      1. Risk of stress-ulcer related GI Bleeding in the ICU: 25%
    2. Discontinue prophylaxis on transfer out of Intensive Care unit
      1. Risk of Stress Ulcer related GI Bleeding drops to <1% outside the ICU
  3. General Measures
    1. Avoid NSAIDS in ICU patients
    2. Stop Aspirin in primary prevention (no known Coronary Artery Disease)
    3. Initiate early Enteral Nutrition
  4. Option 1: Maintain gastric pH > 4
    1. Proton Pump Inhibitor (PPI)
      1. Preparations
        1. Omeprazole (Prilosec) 20-40 mg orally daily
        2. Pantoprazole (Protonix) 40 mg IV daily
      2. Adverse effects
        1. Risk of Nosocomial Pneumonia (Protect against Aspiration Pneumonia)
        2. Risk of Clostridium difficile
      3. Efficacy
        1. May be more effective than H2 Blockers in ICU Stress Ulcer related GI Bleeding (variable evidence)
          1. Alhazzani (2013) Crit Care Med 41(3): 693-705 [PubMed]
    2. H2 Antagonist IV infusion
      1. Preparations
        1. Famotidine 20 mg IV every 12 hours
        2. Ranitidine 50 mg IV every 8 hours
        3. Avoid Cimetidine due to Drug Interactions
        4. Modify dose when GFR <50ml/min
      2. Efficacy
        1. May be preferred over PPI with fewer adverse effects
        2. Some studies suggest similar efficacy in prevention of GI Bleeding
        3. (2014) Presc Lett 21(4): 24
        4. MacLaren (2014) Crit Care Med 42(4): 809-15 [PubMed]
  5. Option 2: Topical protectants
    1. Sucralfate (carafate) slurry 1 g PO q6h
    2. Misoprostol 200 ug PO qid
    3. Less risk of Aspiration Pneumonia than Option 1

IX. References

  1. Marino (2014) ICU Book, p. 77-88
  2. Internet Book of Critical Care (Farkas, EM-Crit)
    1. https://emcrit.org/ibcc/guide/
  3. (2022) Presc Lett 29(9): 53

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Curling Ulcer (C0010474)

Definition (MSH) Acute stress DUODENAL ULCER, usually observed in patients with extensive third-degree burns.
Concepts Disease or Syndrome (T047)
MSH D004381
SnomedCT 39755000
English Curling's Ulcer, Curlings Ulcer, Curling's ulcer, Curling ulcers, Curling Ulcer, curling ulcer, curlings ulcer, curling ulcers, curling's ulcer, curlings ulcers, Ulcer, Curling, Curling's ulcers, Curling's ulcers (disorder), Curling
Japanese カーリング潰瘍, カーリングカイヨウ
Czech Curlingův vřed
French Ulcère de Curling
German Curling-Ulkus
Hungarian Curling fekély
Italian Ulcera di Curling
Spanish úlceras de Curling (trastorno), úlceras de Curling, Úlcera de Curling
Dutch Curling-ulcus
Portuguese Úlcera de Curling

Ontology: Acute gastric mucosal erosion (C0267112)

Concepts Disease or Syndrome (T047)
ICD10 K25
SnomedCT 444926003, 2367005, 18338004, 18665000, 182945005
Dutch acute maagerosies
French Erosions gastriques aiguëes
German akute Magenerosionen
Italian Erosioni gastriche acute
Portuguese Erosões gástricas agudas
Spanish Erosiones gástricas agudas, gastritis erosiva aguda, gastritis aguda erosiva, gastritis erosiva aguda (trastorno), erosión aguda de la mucosa gástrica, erosión aguda de la mucosa gástrica (trastorno), erosión mucosa gástrica aguda (trastorno), erosión mucosa gástrica aguda, erosión aguda de estómago
Japanese 急性胃粘膜びらん, キュウセイイネンマクビラン
English acute erosive gastritis (diagnosis), acute erosive gastritis, Acute gastric mucosal erosion, Acute gastric erosions, erosion (acute) of stomach, Acute erosive gastritis (disorder), Acute erosive gastritis, Erosion;gastric;acute, acute gastric erosions, gastritis erosive, erosive gastritis, haemorrhagic gastritis, acute hemorrhagic gastritis, erosive gastropathy, gastritis hemorrhagic, hemorrhagic gastritis, Acute erosion of stomach, Acute gastric mucosal erosion (disorder), Acute gastric mucosal erosion, NOS, acute gastric erosion
Czech Akutní žaludeční eroze
Hungarian Acut gastrikus erosiók

Ontology: Prophylaxis against gastrointestinal ulcer (C0919581)

Concepts Therapeutic or Preventive Procedure (T061)
Italian Profilassi dell'ulcera gastrointestinale, Profilassi per ulcera gastrica
Dutch maagulcusprofylaxe, profylaxe tegen maagdarmulcus
French Prophylaxie anti-ulcère gastrique, Prophylaxie contre l'ulcère gastro-intestinal
German Prophylaxe gegen Magengeschwuer, Prophylaxe gegen Gastrointestinalulkus
Portuguese Profilaxia de úlcera gástrica, Profilaxia contra úlcera gastrointestinal
Spanish Profilaxis de la úlcera gástrica, Profilaxis contra la úlcera gastrointestinal
Japanese 胃潰瘍予防, 胃腸潰瘍予防, イチョウカイヨウヨボウ, イカイヨウヨボウ
Czech Prevence vředové choroby gastroduodenální, Prevence žaludečního vředu
Hungarian Gyomorfekély profilaxis, Gastrointestinalis fekély profilaxis
English Gastric ulcer prophylaxis, Prophylaxis against gastrointestinal ulcer