What is the management of Curling's (stress-induced gastric) ulcer?

Management of Curling's Ulcer

Initiate stress ulcer prophylaxis immediately with either proton pump inhibitors (PPIs) or H2-receptor antagonists (H2RAs), combined with early enteral nutrition when feasible, in all critically ill burn patients with risk factors for gastrointestinal bleeding. 1, 2

Immediate Prophylactic Management

Risk Assessment

• Curling's ulcers develop within 24-48 hours after severe thermal injury, particularly in patients with burns >40% total body surface area 2, 3, 4
• The strongest predictors requiring prophylaxis include:
  • Mechanical ventilation >48 hours 1, 2
  • Coagulopathy (OR = 4.3 for GI bleeding) 2
  • Hypovolemic shock causing gastric hypoperfusion 2
  • Severe burns (>40% BSA) 3, 4

Pharmacologic Prophylaxis

Start acid suppression therapy upon admission with either option: 1, 2

• PPIs (preferred): Intravenous pantoprazole 40mg daily provides more consistent acid suppression 2
• H2RAs (alternative): Equivalent option per guidelines, though PPIs may offer superior protection 1, 2

The Surviving Sepsis Campaign guidelines recommend either PPIs or H2RAs for stress ulcer prophylaxis in critically ill patients with risk factors (strong recommendation, low quality evidence). 1

Enteral Nutrition Strategy

Initiate early enteral feeding as soon as hemodynamically stable: 1, 2, 3

• Provides direct mucosal protection through dilutional alkalinization of gastric secretions 4
• Deliver 20-25 kcal/kg daily during early catabolic phase 1
• Advance to 25-30 kcal/kg daily during recovery phase 1
• Combined therapy (antacid + H2RA + enteral feeding) reduces complications to 3% compared to historical rates of 33% 3

Duration of Prophylaxis

• Continue prophylaxis throughout the acute burn phase until autografting is complete 4
• Maintain therapy as long as risk factors persist (mechanical ventilation, coagulopathy, critical illness) 2
• Do not discontinue prophylaxis in patients without risk factors 1

Management of Active Bleeding

Initial Resuscitation

If bleeding develops despite prophylaxis: 5

• Target systolic blood pressure 90-100 mmHg (permissive hypotension strategy) 5
• Maintain hemoglobin >7 g/dL (restrictive transfusion strategy) 5
• Correct coagulopathy immediately 5
• Normalize lactate and base deficit 5

Endoscopic Management

Urgent endoscopy (<12 hours) is first-line for diagnosis and treatment: 5

• Perform dual-modality endoscopic hemostasis for active bleeding 5
• Administer IV PPI bolus followed by continuous infusion for 72 hours post-hemostasis 2, 5
• Second endoscopic attempt recommended if rebleeding occurs 5

Rescue Interventions

If endoscopy fails: 5, 6

• Transcatheter angioembolization (e.g., left gastric artery embolization) is preferred over surgery in hemodynamically stable patients 5, 6
• Emergency surgery reserved only for hemodynamically unstable patients with failed endoscopic therapy 5

Monitoring Requirements

• Daily assessment for occult bleeding: monitor hemoglobin, check for melena/hematemesis 2
• Gastric pH monitoring if using antacids (maintain pH >4) 3, 4
• Continue surveillance until burn wounds are fully grafted 4

Critical Pitfalls to Avoid

• Delaying prophylaxis: Must start immediately upon admission, not after bleeding develops 2, 3
• Inadequate enteral nutrition: Early feeding provides independent protection beyond acid suppression 1, 2, 4
• Premature discontinuation: Maintain prophylaxis throughout entire acute phase until autografting complete 4
• Using monotherapy alone: Combined approach (acid suppression + enteral nutrition) superior to single modality 3, 4

The mortality from stress ulcer bleeding in critically ill patients reaches 48.5% compared to 9.1% in those without bleeding, emphasizing the critical importance of aggressive prophylaxis. 2