Stress Ulcer(2009)

Stress UlcerStress Ulcer

Tianjin medical university general hospitalTianjin medical university general hospital

Songtao shouSongtao shou

sex:male age: 75y chief complaints: cough,gasp and spitting for 10 days,fever

for 3 days. lethargy for 1 day.past history : COPD for 10 years.After admission to ICU,we found his stools were dark stool

s. ( no history of peptic ulcer.)Symptoms:cough, expectoration, gasp and fever,without ab

dominal pain .laboratory examination:ABG:pH 7.40,PaO2 50mmHg ,PaCO2 80mmHg

Chest x-ray:Diagnosis: COPD , respiratory failure, pneumonia

lung markings

What should we do next?

laboratory examinationlaboratory examination

1.1.BRT:WBC BRT:WBC 15×1015×1099/L,N 90%,Hb140g/L,PLT 300×10/L,N 90%,Hb140g/L,PLT 300×109 9 /L/L..2.ABG:pH 7.40,PaO2.ABG:pH 7.40,PaO22 50mmHg ,PaCO 50mmHg ,PaCO22 80mmHg 80mmHg

3.stool :OB(++++), WBC(-),RBC(3/hp) 3.stool :OB(++++), WBC(-),RBC(3/hp) the occult blood is positive after admission the occult blood is positive after admission

for 24 hours.for 24 hours.

Diagnosis ?Diagnosis ?1.Respairatory failure1.Respairatory failure2.Bleeding of gastrointestinal2.Bleeding of gastrointestinal• Peptic ulcerPeptic ulcer• Acute bacillary dysenteryAcute bacillary dysentery• Stress ulcer syndromeStress ulcer syndrome

Therapy?Therapy?11. positively correct the primary disease.. positively correct the primary disease.

2. Antiacides(Omeprazole) 2. Antiacides(Omeprazole)

3. 3. Cytoprotection(Cytoprotection(Sucralfate)Sucralfate)

4. H4. H22 recepter antagonist(cimetidine) recepter antagonist(cimetidine)

5. enteral feeding5. enteral feeding

contentscontents

• Definition of stress ulcer syndrome• Etiology of stress ulcer syndrome• Characters of stress ulcer syndrome Characters of peptic ulcer• Pathophysiology of stress ulcer• Diagnosis of stress ulcer syndrome• Treatment of stress ulcer• Prophylaxis of stress ulcer• insight

Stress?Stress?

• To subject to physical or mental pressure, tension, or strain.

• In medicine,stress refers to physical or psychological trauma.

fight or flight

LC-sympathetic nerve-adrenal medullar

Stress

neuroendocrine

Cell fluid

H-P-A system

Other hormones

AP

HSPCytokineenzyme

diseases stress

neuroendocrineCell,body fluid

hypermetabolism

Cell,tissue,organ and system dysfunction

Change from gene to whole body

Clinical expression of stress reaction

LC

cerebrum

brainstem

Spinal cord

adrenal

kidney

LC-Sympathetic-adrenal gland medullar

LC

Main effectsMain effects

• CNS ——

Brain

Adr-N

stressor

PVNCRH

excite 、 alert ;

nervous 、 anxious

Active HPA axis②

①

1 catabolize glycogen and fat ， 2 HR,BP ， 3 redistribution of blood to ensure the supply of main organs. 4 dilate bronchi,oxygen supply

Periphery effects: CA defense

1.organ ischemia 2.hypertension 3.thrombosis 4.oxygen expenditure

Adverse effects

stressor

CRH↑

ACTH↑

GC↑

Cerebral cortex and limbic system 、 amygdaloid body 、 hippocamp

Hypothalamus-pituitary-adrenalHypothalamus-pituitary-adrenal

Main effectsMain effects

• (1)CNS

stressor

PVN CRH↑ACTH↑

control behaviour and feeling—— eustress:euphoria

distress:anxious 、 depression

hypoxia

Amygdaloid body

endorphin ↑

LC-NE axis

(2)Periphery effects(2)Periphery effects

GC ↑ >25~37mg/d GC ↑ >25~37mg/d 1.Blood glucose ↑2.Sustain reactivity of circular system to

catecholamine.3.anti-inflammation,anti-sensitivity 、 s

table lysosome membrane

Adverse effects of GC↑Adverse effects of GC↑

1.inhibit immunity

2.inhibit develope

3.behavior abnormal

4.inhibit sex axis and thyroid axis

5.change metabolism

Other hormonesOther hormones

• 1 glucagon↑ ， insulin↓• 2 ADH↑• 3 -endorphine↑• 4 sex hormone and thyroxine↓

Other hormonesOther hormones

Reaction of cell and body fluidReaction of cell and body fluid

Cell

AP

HSP

Some enzymes

Some cytokines

stressors

stressors

Sympathetic nerve-adrenal medullarCA

H-P-A activeGC

ALD 、 ADH 、 Endopeptide,ectInsulin

Neu

roend

ocrine ch

ang

e

AP

HSP

Metab

olic ch

ange

summarysummary

Several Several conceptsconcepts

1.stress disease The disease is caused all by stress.eg:stress ulcer

2.stress related disease the disease is related to stress.eg:CAD 、 PH or asthma

Stress ulcerStress ulcer

Ulcer?Ulcer?

• A lesion of the mucous membrane that is accompanied by edema and necrosis of surrounding tissue, usually resulting from inflammation.

• It achieves to the muscularis mucosa.

What is stress ulceration?What is stress ulceration?

• Stress ulceration is a gastrointestinal mucosal injury related to critical illness.

• The ulceration may vary from diffuse superficial injuries to deep hemorrhaging ulcerations.

Why is it important?Why is it important?

• There is a relationship between severity of disease and incidence of ulceration

• A GI bleed may be a marker of the patient’s condition

Stress ulcer syndrome(SUS)Stress ulcer syndrome(SUS)

It is the acute changes confined to the gastric mucosa under the condition of physiologic or psychological stress.the mucosal lesion and associated clinical bleeding or perforation have been termed SUS.

sussus

• It was introduced by Hans Selye in 1936 to describe the association between psychosomatic illness and peptic ulcer.

• The incidence of stress ulcer ranges from 20% to 100% in ICU (Intensive care unit) patients.

What causes it?What causes it?

• Ulceration is caused by ischemic injury to the gastric mucosa, loss of cytoprotectants and assault by gastric acid.

• The mucosa is injured and cannot repair itself sufficiently well to ward off aggressive factors present in the gut lumen (these aggressors include gastric acid, bile and digestive enzymes. )

Stress Ulceration Risk FactorsStress Ulceration Risk Factors

• The major risk factors are respiratory failure, coagulopathy, sepsis, hypotension and hepatic and renal failure.

there is a good relationship between severity of illness (as determined by, for example, APACHE II scores) and incidence of ulceration.

Moreover, the longer a patient in ICU, the more likely they are to have a GI bleed . Patients who are likely to have a number of these risk factors – burns patients for example (ventilated, hypotensive, coagulopathic), are more likely to have ulceration and bleeding.

stress ulcer syndrome appears to be mucosa ischemia resulting form splanchnic hypofusion in the setting of physiologic stress and an acid

Pathogenesis of stress ulcer

（ 1 ） mucosa ischemia

（ 2 ） H+ diffuse to intramucosa

（ 3 ） others : acidosis

CAMucosa barrier

H+ diffuse tointramucosa

Blood flow H+pump out ulcer

GC stressor

Mucosa ischemia

Gastric mucosal circulationGastric mucosal circulation

• Disproportionate vasoconstrictor response to stress– Neural nor-adrenaline and circulating adrenalin

e have similar effects on vasoconstriction in gastric mucosal and systemic vascular beds

– Renin-angiotensin system and to a lesser degree vasopressin are responsible for the disproportionate response.

The mucosa is compromised by ischemia and attacked (mostly) by acid. It is The mucosa is compromised by ischemia and attacked (mostly) by acid. It is injured, and, due to the presence of acid, cannot repair itself (hostile injured, and, due to the presence of acid, cannot repair itself (hostile environment).environment).

The use of external agents to neutralize acid resolves this problem.The use of external agents to neutralize acid resolves this problem.

Diagnosis of susDiagnosis of sus

• Symptom most patients have no symptoms. Abdominal pain and perforation are rare.

• Body signs• Lab test Positive occult blood in both vomitus and m

elena,these lesions have been found with endosocopy as early as 5h after ICU admission and most will be evident within 72h.

• Endoscopy:Commonly mucosal erosions are found in the fundus or acid secreting parts of the stomach .

Important sources of OB errorImportant sources of OB error

False –positive• Cimetidine• pH=2~4• Red meat • Horseradish• Raw turnips • Apple,orange,banana

False –negative• Antacids• pH<2• Vitamine C

characters acute multi ， superficial easy to heal ； bleeding and

perforation are seldom

Differences between PU and SUDifferences between PU and SUPU SU

Attack chronic acute

Location antrum cardia ,fundus and bodcardia ,fundus and bodyy

Ulceration Single or two MultipleMultiple

Signs and symptoms

Abdominal pain,perforation and bleeding

Abdominal pain, Abdominal pain, Bleeding and Perforation are unusualPerforation are unusual

diagnose barium meal and endoscope

EndoscopicEndoscopic

The mucosa plica in the gastric body is smooth.

Before making gastroscope,we have to fulfill the stomach with enough air,so under gastroscope the mucosa is very smooth.pylorus is round and always in contraction.

Mucus lake

thrombosis Peptic ulcer+complication(Bleeding)

Minal clot

petechiapetechia

Treatment StrategyTreatment Strategy

• Patients who do not have one of the six major risk factors do not require treatment.

• Patients in shock, sepsis, respiratory, hepatic or renal failure, or who have a coagulopathy, who are admitted to intensive care, should all be given stress ulcer prophylaxis.

The goal of therapyThe goal of therapy

Stress ulcersStress ulcers are not deep craters like those s are not deep craters like those seen in peptic ulcer disease,but are superficial een in peptic ulcer disease,but are superficial erosions confined to the surface of the mucoserosions confined to the surface of the mucosa.Therefore, the goal of therapy is not so muca.Therefore, the goal of therapy is not so much to prevent their appearance but to limit the ih to prevent their appearance but to limit the incidence of troublesome bleeding.ncidence of troublesome bleeding.

• Da huang

Principle of TreatmentPrinciple of Treatment

• Cytoprotection(Sucralfate)

• H2 recepter antagonist(cimetidine)

• Antiacides(losec)

• Surgery therapy

• Enteral feeding

• Ranitidine and sucralfate are the most effective agents. Ranitidine is associated with a lower incidence of clinically significant bleeding, sucralfate with a lower incidence of pneumonia.

Principle ofPrinciple of enteral feeding enteral feeding

1.1.To neutralize gastric pH(to dilute the relatively To neutralize gastric pH(to dilute the relatively acid enviroment)acid enviroment)

2.2.To provide the cells of the gastric mucosa with To provide the cells of the gastric mucosa with a nutrient.the cells may use luminal nutrients as a nutrient.the cells may use luminal nutrients as a source of energy to produce the protective sura source of energy to produce the protective surface lining.face lining.

3.3.It solves the problems of nutrition and stress uIt solves the problems of nutrition and stress ulcer prophylaxis.lcer prophylaxis.

Prophylaxis of stress ulcerProphylaxis of stress ulcer

• Enteral feedings

• Control of the gastric PH

• Cytoprotection

• Hemodynamatic management

• Oxygen supplement

Prophylaxis Prophylaxis

• prophylaxis for SUS should be confined to carefully selected at-risk patients

• Stress ulcers are often present within hours of admission to an intensive care unit.So,to a certain extent ,it is more important to prophylaxis stress ulcers than to treat them.

ImportantsImportants

• Etiology and risk factors of sus

• Characters of sus

• Prophylaxis of sus

SUS are often viewed as a primary illness SUS are often viewed as a primary illness instead of a signal for instead of a signal for mucosal ischemiamucosal ischemia. The . The misconception has created some confusion misconception has created some confusion about the appropriate therapy for stress ulcers about the appropriate therapy for stress ulcers and specifically about the role of gastric acid and specifically about the role of gastric acid suppression therapy.through the chapter ,we suppression therapy.through the chapter ,we know stress ulcers are a manifestation of know stress ulcers are a manifestation of mucosa ischemia and mucosa ischemia and NOT NOT a manifestation of a manifestation of gastric hyperacidity.gastric hyperacidity.

insightinsight• Ulcer achieves to the muscularis

mucosa

• Stress ulcers are confined the gastric mucosa

• So ,stress ulcers are not the real ulcers

THANK YOUTHANK YOU