What type of gastric ulcer is commonly associated with central nervous system (CNS) injury?

Curling's Ulcer is the Gastric Ulcer Associated with Central Nervous System Injury

Patients with central nervous system injury commonly develop Curling's ulcers, which are stress-related gastric ulcers that occur in response to severe physiological stress.

Understanding Stress Ulcers in CNS Injury

Stress ulcers are multiple, superficial erosions that primarily affect the fundus and body of the stomach. They develop in response to severe physiological stress, with two main variants:

• Curling's ulcers: Occur following severe burns, trauma, and CNS injuries
• Cushing's ulcers: Specifically associated with intracranial pressure and head injury

Pathophysiology of Curling's Ulcers

The development of Curling's ulcers in CNS injury patients involves several mechanisms:

1. Stress-induced physiological changes:

   • Increased gastric acid secretion due to vagal stimulation
   • Elevated histamine release
   • Increased production of glucocorticoids 1

2. Circulatory disturbances:

   • Shock-induced reduction in gastric blood supply
   • Mucosal ischemia leading to necrosis of apical mucosal cells 2

3. Disruption of the gastric mucosal barrier:

   • Gastroduodenal reflux
   • Altered mucosal defense mechanisms 1

Clinical Presentation and Diagnosis

The diagnosis of Curling's ulcers in CNS injury patients is challenging because:

• Patients often cannot express abdominal pain due to altered mental status
• Diagnosis is frequently delayed, contributing to high mortality (up to 60%) 3

Key Clinical Signs

• Abdominal distension
• Fever
• Tachypnea
• Tachycardia
• Hypotension
• Hematemesis or melena (when bleeding occurs) 3

Diagnostic Approach

1. Endoscopy: The mainstay of diagnosis, allowing direct visualization of gastric erosions 1
2. Chest X-ray: May show pneumoperitoneum if perforation has occurred
3. Peritoneal lavage: Can reveal bile-like ascites in cases of perforation 3

Management Approach

Prevention

Prevention is critical in high-risk CNS injury patients:

• Early enteral nutrition when possible
• Stress ulcer prophylaxis with acid suppression therapy
• Regular monitoring for signs of GI bleeding 1

Treatment

For established Curling's ulcers:

1. Medical management:

   • Volume resuscitation for bleeding
   • Nasogastric aspiration
   • Antacid administration
   • Proton pump inhibitors or H2 receptor antagonists 1

2. Endoscopic intervention:

   • First-line approach for bleeding ulcers
   • Allows for direct hemostatic therapy 4

3. Surgical intervention:

   • Reserved for patients with continued bleeding despite medical management
   • Options include vagotomy, pyloroplasty, and oversewing of ulcers 1

Prognosis and Complications

Curling's ulcers in CNS injury patients carry significant morbidity and mortality:

• Hemorrhage is the most common complication
• Perforation is less common but carries high mortality
• Presence of shock after perforation correlates strongly with poor survival 3

Key Differences from Other Ulcer Types

• H. pylori ulcers: Associated with bacterial infection, not stress response 5
• Duodenal ulcers: Primarily affect the duodenum rather than stomach fundus/body
• Barrett's ulcers: Associated with chronic acid reflux and metaplasia, not acute stress

Conclusion

Early recognition and aggressive management of Curling's ulcers in CNS injury patients are essential to improve outcomes. The high mortality rate associated with these ulcers underscores the importance of preventive measures and prompt intervention when they occur.