Stress Ulcer(2009)

stress ulcer

1. Stress UlcerStress Ulcer
Tianjin medical university general hospitalTianjin medical university general hospital
Songtao shouSongtao shou

2. 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 stools.
( no history of peptic ulcer.)
Symptoms:cough, expectoration, gasp and fever,without
abdominal pain .
laboratory examination:
ABG:pH 7.40,PaO
2
50mmHg ,PaCO
2
80mmHg
Chest x-ray:
Diagnosis:
COPD , respiratory failure, pneumonia

3. lung markings

4. What should we do next?

5. laboratory examinationlaboratory examination
1.1.BRT:WBC BRT:WBC 15×1015×10
99
/L,N 90%,Hb140g/L,PLT 300×10/L,N 90%,Hb140g/L,PLT 300×10
9 9
/L/L..
2.ABG:pH 7.40,PaO2.ABG:pH 7.40,PaO
22 50mmHg ,PaCO 50mmHg ,PaCO
22 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.

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

7. 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. H
22 recepter antagonist(cimetidine) recepter antagonist(cimetidine)
5. enteral feeding5. enteral feeding

8. 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

9. Stress?Stress?
•To subject to physical or mental pressure,
tension, or strain.
•In medicine,stress refers to physical or
psychological trauma.

10. fight or
flight

11. LC-sympathetic nerve-adrenal medullar
Stress
neuroendocrine
Cell fluid
H-P-A system
Other hormones
AP
HSP
Cytokine
enzyme

12. diseases stress
neuroendocrine
Cell,body fluid
hypermetaboli
sm
Cell,tissue,organ and system dysfunction

13. Change from gene
to whole body
Clinical expression of
stress reaction

14. LC
cerebrum
brainstem
Spinal cord
adrenal
kidney
LC-Sympathetic-adrenal gland medullar

15. LC

16. Main effectsMain effects
•CNS ——


Brain
Adr-N
stresso
r
PVN
CRH
excite、 ;
alert
nervous、anxious

ActiveHPAaxis
②
①

17. 1 catabolize glycogen and
fat，
2 HR­,BP ­ ，
3 redistribution of blood
to ensure the supply of main
organs.
4 dilate bronchi,oxygen
supply

nPeriphery effects: CA ­
defense

18. 1.organ ischemia
2.hypertension
3.thrombosis
4.oxygen expenditure
Adverse effects

19. stressor
CRH↑
ACTH↑
GC↑
Cerebral cortex and
limbic
system、amygdaloid
body、hippocamp
Hypothalamus-pituitary-adrenalHypothalamus-pituitary-adrenal

20. Main effectsMain effects
•(1)CNS
stresso
r
PVN CRH↑
ACTH↑
control behaviour and feeling——
eustress:euphoria
distress:anxious、depression
hypoxia
Amygdaloid body
endorphin ↑
LC-NE
axis

21. (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、stable lysosome
membrane

22. 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

23. Other hormonesOther hormones
•1 glucagon↑， insulin↓
•2 ADH↑
•3 b-endorphine↑
•4 sex hormone and thyroxine↓
Other hormonesOther hormones

24. Reaction of cell and body fluidReaction of cell and body fluid
Cell
AP
HSP
Some enzymes
Some cytokines
stressors

25. s
t
r
e
s
s
o
r
s
Sympathetic nerve-adrenal medullar®CA­
H-P-A active®GC­
ALD、ADH、Endopeptide,ect­
Insulin¯
N
e
u
r
o
e
n
d
o
c
r
i
n
e
c
h
a
n
g
e
AP ­
HSP ­
M
e
t
a
b
o
l
i
c
c
h
a
n
g
e
summarysummary

26. Several Several
conceptsconcepts
1.
stressdisease


Thediseaseiscausedall
. :
bystressegstressulcer
2.
stressrelateddisease

the disease is related to
. :
stressegCAD
、
PH or
asthma

27. Stress ulcerStress ulcer

28. 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.

29. 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.

30. 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

31. 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.

32. 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.

33. 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. )

34. 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.

35. 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

36. （1
）

mucosa ischemia
（2）H
+

diffuseto
intramucosa
（3） :
others acidosis
CA­
Mucosa
barrier¯
H
+
diffuse to
intramucosa
Blood flow¯ H
+
pump out¯
ulcer
GC ­
stressor
Mucosa
ischemia

37. Gastric mucosal circulationGastric mucosal circulation
•Disproportionate vasoconstrictor response
to stress
–Neural nor-adrenaline and circulating
adrenaline 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.

38. 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.

39. 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
melena,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 .

40. 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

41. characters
 acute
 multi，
superficial

easy toheal
；

bleedingandperforation

areseldom

42. Differences between PU and SUDifferences between PU and SU
EndoscopicEndoscopic barium meal and
endoscope
diagnose
Abdominal pain, Abdominal pain,
Bleeding and
Perforation are unusualPerforation are unusual
Abdominal
pain,perforation
and bleeding
Signs and
symptoms
MultipleMultipleSingle or twoUlceration
cardia ,fundus and cardia ,fundus and
bodybody
antrumLocation
acutechronicAttack
SUPU

43. The mucosa
plica in the
gastric body is
smooth.

44. 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.

45. Mucus lake

46. thrombosis Peptic ulcer
+
complication
(Bleeding)

47. Minal clot

48. petechiapetechia

49. 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.

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

51. •Da huang

52. Principle of TreatmentPrinciple of Treatment
•Cytoprotection(Sucralfate)
•H
2 recepter antagonist(cimetidine)
•Antiacides(losec)
•Surgery therapy
• Enteral feeding

53. •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.

54. 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 a source of energy to produce the protective
surface lining.surface lining.
3.3.It solves the problems of nutrition and stress It solves the problems of nutrition and stress
ulcer prophylaxis.ulcer prophylaxis.

55. Prophylaxis of stress ulcerProphylaxis of stress ulcer
•Enteral feedings
•Control of the gastric PH
•Cytoprotection
•Hemodynamatic management
•Oxygen supplement

56. 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.

57. ImportantsImportants
•Etiology and risk factors of sus
•Characters of sus
•Prophylaxis of sus

58. 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.

59. insightinsight
•Ulcer achieves to the muscularis
mucosa
•Stress ulcers are confined the
gastric mucosa
•So ,stress ulcers are not the real
ulcers

61. THANK YOUTHANK YOU