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Stress ulcer

A stress ulcer is a lesion of the mucous membrane of the digestive tract, which develops following acute stress, such as that caused by a disease or severe physical shock. In fact, it can arise after an extensive burn or a head injury. In these cases, we speak, respectively, of Curling ulcer and Cushing ‘s ulcer.

The stress ulcer can have different degrees: in some cases, the erosions are superficial and asymptomatic, with occult bleeding. In others, however, the lesions are deep, symptomatic, and with manifest bleeding. They generally affect the body and the bottom of the stomach, but apparently, albeit less frequently, also in the gastric antrum, duodenum, and esophagus.

Stress ulcers: causes

The primary causes of stress ulcers are:

  • extensive burns affecting more than 30% of the body;
  • head trauma;
  • serious conditions, such as brain tumors.

The secondary causes that contribute to the onset of the stress ulcer are:

  • Mechanical ventilation for more than 48 hours;
  • low coagulation;
  • septic shock;
  • use of vasopressor drugs (adrenaline, noradrenaline, etc.);
  • use of high-dose corticosteroids (more than 250mg per day);
  • hepatic, renal, or multi-organ failure;
  • previous history of gastrointestinal bleeding within the past year;
  • lack of adequate disinfection in intensive care units.

Stress ulcer: symptoms

Symptoms of a stress ulcer can be:

  • caffeine vomit, in which the color and consistency of the vomit are reminiscent of coffee grounds. This particularity indicates the presence of bleeding in the upper gastrointestinal tract;
  • hematemesis, which indicates the condition in which blood is vomited. The color of the regurgitation is bright or dark red;
  • Indicates the presence of blood in the stool;
  • abdominal pain;
  • nausea;
  • orthostatic hypotension, which develops only in cases of severe bleeding.

Differential diagnosis

The symptoms listed above are not unique to the stress ulcer. In fact, they could indicate the presence of a different pathology, such as:

  • peptic ulcer;
  • gastritis induced by non-steroidal anti-inflammatory drugs (NSAIDs);
  • alcoholic gastropathy;
  • gastroesophageal reflux;
  • gastric or esophageal cancer;
  • gastroparesis;
  • pancreatic cancer;
  • biliary colic;
  • uremic gastropathy;

Stress ulcer: cure

Pharmacological treatments for stress ulcers involve the use of:

  • proton pump inhibitors (omeprazole, esomeprazole, etc.);
  • H2 antagonists (ranitidine, famotidine, etc.);
  • anti-ulcer medications such as sucralfate.

Proton pump inhibitors are considered superior to H2 antagonists in preventing stress ulcers in severely ill patients.

In the case of a bleeding ulcer it is possible to stop the bleeding through the following endoscopic therapies:

  • epinephrine injection;
  • electro-cauterization of the bleeding ulcer;
  • suture of the lesion.

Patients who do not respond to endoscopic therapies may require embolization of the hemorrhagic vessel or, ultimately, surgery after thorough evaluation. The latter is instead necessary in the case of a perforating stress ulcer which, if not treated surgically, can have a fatal outcome as reported in the literature.

The treatment of stress ulcers is also aimed at avoiding the complications that can follow from the ulcer. In this case, the interventions include:

  • early enteral feeding;
  • positioning of the nasogastric tube;
  • rehydration;
  • blood transfusions.


A stress ulcer can have the following complications:

  • bleeding;
  • anemia;
  • narrowing of the digestive system;
  • drilling;
  • peritonitis;
  • gastro-colic fistula;
  • hemorrhagic shock;


Generally, patients with stress ulcers have a negative prognosis, mainly due to the concomitant presence of serious pathologies. However, ulcer bleeding is in itself an important risk factor, associated with serious problems, independent of previous pathologies. Furthermore, the often unstable conditions of patients with stress ulcers make it difficult to use endoscopic or surgical techniques to stop bleeding. For this reason, the clinical recommendation is to focus on the adoption of aggressive prophylactic measures in patients at risk of stress ulcers.


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