Stress Ulceration (Stress-Related Mucosal Disease)
Bleeding after hypoxic injury to the stomach is called stress ulceration or stress-related mucosal disease, which develops from gastric mucosal ischemia caused by hypoperfusion and shock. 1, 2
Pathophysiology
The fundamental mechanism underlying stress ulceration involves:
- Profound regional gastric ischemia resulting from severe and disproportionate gastric vasoconstriction during shock states 2
- The splanchnic vascular bed demonstrates remarkable sensitivity to the renin-angiotensin axis, which mediates the selective vasospasm that causes mucosal injury 2
- Gastric mucosal hypoperfusion disrupts protective mechanisms against gastric acid, leading to rapid development of hemorrhagic ulceration 1, 3
- This process occurs quickly—gastric stress ulceration develops rapidly in patients after severe trauma and shock 1
Key Risk Factors
The strongest predictors for stress ulcer bleeding include:
- Shock (especially septic shock) is the most important risk factor 1, 3
- Mechanical ventilation for >48 hours 4
- Coagulopathy 4
- Multiple organ failure syndrome 1
- Head trauma or neurosurgical procedures (which can cause gastric acid hypersecretion) 3
Clinical Significance
Bleeding from stress ulceration is rare but represents a very serious complication with high mortality when it occurs 1. The condition is part of the broader multiple splanchnic organ failure syndrome that includes nonocclusive bowel ischemia, ischemic colitis, and shock liver 2.
Prevention and Management
The most effective prophylaxis is optimal resuscitation and intensive care aimed at improving oxygenation and microcirculation—this takes priority over pharmacologic interventions 1, 3.
For pharmacologic prophylaxis in at-risk patients:
- Stress ulcer prophylaxis should be given to patients with sepsis or septic shock who have risk factors for gastrointestinal bleeding 4
- Either proton pump inhibitors or histamine-2 receptor antagonists can be used when prophylaxis is indicated 4
- Sucralfate is the most cost-effective option and strengthens mucosal defensive mechanisms 3
- Do not provide stress ulcer prophylaxis to patients without risk factors for GI bleeding 4
Once profuse bleeding has started, measures other than aggressive treatment of shock and sepsis are usually unsuccessful 1. Endoscopic therapy with thermal methods or hemostatic clips combined with epinephrine injections may be attempted in stable patients 5, but immediate operation is indicated for patients with rapidly exsanguinating ulcer hemorrhage and hemodynamic instability refractory to endoscopic control 6.