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Stress Ulcer: Causes, Symptoms and Treatment

A stress ulcer is an acute gastric lesion that develops rapidly in critically ill patients or those under severe physiological stress. It can lead to dangerous gastrointestinal bleeding.

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Things worth knowing about "Stress Ulcer"

A stress ulcer is an acute gastric lesion that develops rapidly in critically ill patients or those under severe physiological stress. It can lead to dangerous gastrointestinal bleeding.

What Is a Stress Ulcer?

A stress ulcer is an acute injury to the lining of the stomach (gastric mucosa) that develops in the context of severe illness or critical medical conditions. Unlike a typical peptic ulcer, which forms gradually over weeks or months, a stress ulcer can develop within hours to a few days. It is a serious complication seen predominantly in intensive care unit (ICU) patients and, if left untreated, can lead to life-threatening gastrointestinal bleeding.

Causes and Risk Factors

Stress ulcers form when the body is under extreme physiological stress, leading to reduced blood flow to the gastric mucosa and a breakdown of the protective barrier lining the stomach. Common risk factors include:

Severe burns (known as Curling ulcer)
Severe traumatic brain injury or neurosurgery (known as Cushing ulcer)
Sepsis (life-threatening bloodstream infection)
Multi-organ failure
Mechanical ventilation for more than 48 hours
Coagulopathy (blood clotting disorders)
Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or diclofenac
Major trauma or surgery

Symptoms

Stress ulcers are often initially asymptomatic, as critically ill patients may be sedated or unable to report symptoms. They typically become apparent only when complications arise:

Hematemesis – vomiting of bright red blood or coffee-ground material
Melena – black, tarry stools indicating upper gastrointestinal bleeding
Hypotension and tachycardia – low blood pressure and rapid heart rate due to blood loss
Anemia – caused by ongoing blood loss
Rarely: acute abdominal pain if the ulcer perforates

Diagnosis

The diagnosis of a stress ulcer is typically confirmed by upper gastrointestinal endoscopy (esophagogastroduodenoscopy, EGD), which allows direct visualization of the gastric mucosa and simultaneous treatment of any bleeding. Additional diagnostic steps include:

Complete blood count to assess hemoglobin levels and estimate blood loss
Coagulation studies to evaluate bleeding risk
CT imaging if perforation is suspected

Treatment

Pharmacological Therapy

The cornerstone of treatment is reducing gastric acid production to promote mucosal healing:

Proton pump inhibitors (PPIs) such as pantoprazole or omeprazole – first-line agents that effectively suppress acid secretion
H2-receptor antagonists such as famotidine – used as an alternative when PPIs are not suitable

Endoscopic Therapy

In cases of active bleeding, endoscopic intervention can be performed during the same procedure as diagnosis. Options include injection of adrenaline, placement of hemostatic clips, or thermal coagulation of the bleeding vessel.

Surgical Therapy

Surgery is reserved for rare cases in which endoscopic control of bleeding fails or perforation of the ulcer has occurred.

Prophylaxis

In high-risk ICU patients -- particularly those on mechanical ventilation or with coagulopathy -- stress ulcer prophylaxis with PPIs or H2-blockers is recommended to prevent the development of stress ulcers and their complications.

Prognosis

The prognosis depends largely on the severity of the underlying condition and the extent of bleeding. When identified early and treated appropriately, bleeding can be controlled successfully in most cases. However, untreated stress ulcers carry a significant risk of mortality, particularly in already critically ill patients.

References

Cook DJ, Fuller HD, Guyatt GH et al. - Risk factors for gastrointestinal bleeding in critically ill patients. New England Journal of Medicine, 1994; 330(6): 377-381.
Lanza FL, Chan FK, Quigley EM - Guidelines for prevention of NSAID-related ulcer complications. American Journal of Gastroenterology, 2009; 104(3): 728-738.
Krag M, Marker S, Perner A et al. - Pantoprazole in Patients at Risk for Gastrointestinal Bleeding in the ICU. New England Journal of Medicine, 2018; 379(23): 2199-2208.

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