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Stress ulcer disease in the burned patient

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Abstract

Stress-induced ulcers of the stomach and duodenum in massively burned patients, otherwise known as Curling's ulcers, result from a defect in the mucosal barrier to secreted acid. The etiology of this defect is related, at least in part, to mucosal ischemia, which is aggravated by hypotension, sepsis, and hypoxia. Early prophylactic administration of antacids and cimetidine, either singly or in combination, has significantly reduced the occurrence of the life-threatening complications of these lesions. When preventive measures have failed or have not been utilized and massive bleeding or perforation has occurred, these complications of Curling's ulcer appear to be best treated by gastric resection combined with vagotomy.

Résumé

Les ulcères de stress qui se développent dans l'estomac et le duodénum des brûlés graves (ulcères de Curling) sont dus à un défaut du mécanisme de défense de la muqueuse contre l'acide secrété. Ce défaut est lui-même dépendant, en partie en tout cas, de l'ischémie muqueuse qui est aggravée par l'hypotension, l'infection et l'hypoxie. L'administration prophylactique précoce d'antiacides et de cimétidine, seuls ou combinés, a réduit de façon significative la fréquence des complications graves de ces ulcérations. Si les thérapeutiques préventives échouent, ou si elles n'ont pas été utilisées, et si une hémorragie importante ou une perforation survient, le meilleur traitement est la gastrectomie avec vagotomie.

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References

  1. Cumin, W.: Cases of severe burn, with dissections and remarks. Edinburgh Medical Journal19:337, 1823

    Google Scholar 

  2. Swan, J.: Practical observations: case of a severe burn. Edinburgh Medical Journal19:344, 1823

    Google Scholar 

  3. Curling, T.B.: On acute ulceration of the duodenum in cases of burns. Med. Surg. Trans. (London)25:260, 1842

    Google Scholar 

  4. Moncrief, J.A., Switzer, W.E., Teplitz, C.: Curling's ulcer. J. Trauma4:481, 1964

    Google Scholar 

  5. Pruitt, B.A., Jr., Foley, F.D., Moncrief, J.A.: Curling's ulcer: a clinical-pathology study of 323 cases. Ann. Surg.172:523, 1970

    Google Scholar 

  6. Bruck, H.M., Pruitt, B.A., Jr.: Curling's ulcer in children: a 12 year review of 63 cases. J. Trauma12:490, 1972

    Google Scholar 

  7. Czaja, A.J., McAlhany, J.C., Pruitt, B.A., Jr.: Acute gastroduodenal disease after thermal injury: an endoscopic evaluation of incidence and natural history. N. Engl. J. Med.291:925, 1974

    Google Scholar 

  8. Czaja, A.J., McAlhany, J.C., Pruitt, B.A., Jr.: Acute duodenitis and duodenal ulceration after burns. Clinical and pathological characteristics. J.A.M.A.232:621, 1975

    Google Scholar 

  9. Czaja, A.J., McAlhany, J.C., Jr., Andes, W.A., Pruitt, B.A., Jr.: Acute gastric disease after cutaneous thermal injury. Arch. Surg.110:600, 1975

    Google Scholar 

  10. Czaja, A.J., McAlhany, J.C., Pruitt, B.A., Jr.: Gastric acid secretion in acute gastroduodenal disease after burns. Arch. Surg.111:243, 1976

    Google Scholar 

  11. Rosenthal, A., Czaja, A.J., Pruitt, B.A., Jr.: Gastrin levels and gastric acidity in the pathogenesis of acute gastroduodenal disease after burns. Surg. Gynecol. Obstet.144:232, 1977

    Google Scholar 

  12. McElwee, H.P., Samloff, I.M.: Gastrointestinal alterations and complications in burned troops—serum pepsinogen levels in the thermally injured soldier: a possible predictor of gastroduodenal disease. Ann. Res. Prog. Rpt., US Army Institute of Surgical Research, Brooke Army Medical Center, Fort Sam Houston, Texas 78234, 1978, pp. 106–107

    Google Scholar 

  13. O'Neill, J.A., Jr., Richey, C.R., Mason, A.D., Jr., Villareal, Y.: Effect of thermal burns on gastric mucus production. Surg. Gynecol. Obstet.131:29, 1970

    Google Scholar 

  14. McAlhany, J.C., Jr., Czaja, A.J., Cathcart, R.S., III, Spicer, S.S., Foley, F.D., Pruitt, B.A., Jr.: Histochemical study of gastric mucosubstances after thermal injury: correlation with endoscopic evidence of acute gastroduodenal disease. J. Trauma15:609, 1975

    Google Scholar 

  15. McAlhany, J.C., Jr., Czaja, A.J., Villarreal, Y., Mason, A.D., Jr., Pruitt, B.A., Jr.: The gastric mucosal barrier in thermally injured patients: correlation with gastroduodenal endoscopy. Surg. Forum25:414, 1974

    Google Scholar 

  16. Czaja, A.J., Rizzo, T.A., Jr., McAlhany, J.C., Jr.: Cell renewal kinetics of the gastric mucosa in the thermally injured soldiers. Ann. Res. Prog. Rpt., US Army Institute of Surgical Research, Brooke Army Medical Center, Fort Sam ouston, TX 78234, pp. 243–246, 1975

    Google Scholar 

  17. Pruitt, B.A., Jr., Mason, A.D., Jr., Moncrief, J.A.: Hemodynamic changes in the early postburn patient: the influence of fluid administration and of a vasodialator (hydralazine). J. Trauma11:36, 1971

    Google Scholar 

  18. Harjola, P.T., Sivula, A.: Gastric ulcerations following experimentally induced hypoxia and hemorrhagic shock: in vivo study of pathogenesis in rabbits. Ann. Surg.163:21, 1966

    Google Scholar 

  19. Sales, J., Norton, L., Nolan, P., Rankin, J., Eiseman, B.: Gastric mucosal ischemia in experimental stress ulcer. J. Surg. Res.18:65, 1975

    Google Scholar 

  20. Hottenrot, C., Seufert, R.M., Becker, H.: The role of ischemia in the pathogenesis of stress induced gastric lesions in piglets. Surg. Gynecol. Obstet.146:217, 1978

    Google Scholar 

  21. Ritchie, W.B., Jr.: Acute gastric mucosal damage induced by bile salts, acid and ischemia. Gastroenterology68:699, 1975

    Google Scholar 

  22. Kivilaakso, E., Fromm, D., Silen, W.: Relationship between ulceration and intramural pH of gastric mucosa during hemorrhagic shock. Surgery84:70, 1978

    Google Scholar 

  23. Asch, M.D., Mesaroll, P.M., Mason, A.D., Jr., Pruitt, B.A., Jr.: Regional blood flow in the burned unanesthetized dog. Ann. Res. Prog. Rpt., US Army Institute of Surgical Research, Brooke Army Medical Center, Fort Sam Houston, Texas 78234, Section 25, 30 June 1971

    Google Scholar 

  24. Ritchie, W.P., Jr., Cherry, K.J., Gibb, A.: Influence of methylprednisolone sodium succinate on bile acidinduced acute gastric mucosal damage. Surgery84:283, 1978

    Google Scholar 

  25. Cheung, L.Y., Lowry, S.F.: Effects of intra-arterial infusion of prostaglandin E1 on gastric secretion and blood flow. Surgery83:699, 1978

    Google Scholar 

  26. Levine, B.A., Schwesinger, W.H., Sirinek, K.R., Jones, D., Pruitt, B.A., Jr.: Cimetidine prevents reduction in gastric mucosal blood flow during shock. Surgery84:113, 1978

    Google Scholar 

  27. Hottenrot, C., Seufert, R.M., Kühne, F.W., Büsing, M.: Experimental gastric sympathectomy: an effective prophylaxis of gastric stress lesions. Ann. Surg.186:762, 1977

    Google Scholar 

  28. Menguy, R., Masters, Y.F.: Gastric mucosal energy metabolism and “stress ulceration.” Ann. Surg.180:538, 1974

    Google Scholar 

  29. Mullane, J.F., Pyant, R.L., Jr., Wilfong, R.G., Dailey, W.: Starvation, glucose, and stress ulcers in the rat. Arch. Surg.109:416, 1974

    Google Scholar 

  30. Raulston, G.L., Walker, H.L.: Effect of adrenalectomy on Curling's ulcer formation in the burned rat. Ann. Res. Prog. Rpt., US Army Institute of Surgical Research, Brooke Army Medical Center, Fort Sam Houston, Texas 78234, Section 44, June 1970

    Google Scholar 

  31. Harmon, J.W., Doong, T., Gadacz, T.R.: Bile acids are not equally damaging to the gastric mucosa. Surgery84:79, 1978

    Google Scholar 

  32. Kivilaakso, E., Fromm, D., Silen, W.: Effects of lysolecithin on isolated gastric mucosa. Surgery84:616, 1978

    Google Scholar 

  33. Kivilaakso, E., Silen, W.: Pathogenesis of experimental gastric-mucosal injury. N. Engl. J. Med.301:364, 1979

    Google Scholar 

  34. McAlhany, J.C., Jr., Czaja, A.J., Pruitt, B.A., Jr.: Antacid control of complications from acute gastroduodenal disease after burns. J. Trauma16:645, 1976

    Google Scholar 

  35. Levine, B.A., Teegarden, D.K., McLeod, C.G., Jr., Sirinek, K.R., Pruitt, B.A., Jr.: Cimetidine prevents stress-induced gastric erosions. Surg. Forum28:359, 1977

    Google Scholar 

  36. Levine, B.A., Schwesinger, W.H., Jones, D., Sirinek, K.R.: Histamine receptor control of gastric microvasculature in shock. J. Surg. Res.26:532, 1979

    Google Scholar 

  37. Sirinek, K.R., Levine, B.A., Pruitt, B.A., Jr.: Cimetidine controls postburn gastric edema. Presented at the Eleventh Annual Meeting, American Burn Association, New Orleans, La., March 1979.

    Google Scholar 

  38. McElwee, H.P., Sirinek, K.R., Levine, B.A.: Cimetidine affords protection equal to antacids in prevention of stress ulceration following thermal injury. Surgery86:620, 1979

    Google Scholar 

  39. Priebe, H.J., Skillman, J.J., Bushnell, L.S., Long, P.C., Silen, W.: Antacid versus cimetidine in preventing acute gastrointestinal bleeding: a randomized trial in 75 critically ill patients. N. Engl. J. Med.302:426, 1980

    Google Scholar 

  40. Martin, L.F., Max, M.H., Polk, H.C., Jr: Failure of gastric pH control by antacids or cimetidine in the critically ill: a valid sign of sepsis. Surgery85:59, 1980

    Google Scholar 

  41. Korenmen, M.D., Stubbs, M.B., Fish, J.C.: Intestinal obstruction from medication bezoars. J.A.M.A.240:54, 1978

    Google Scholar 

  42. Ponsky, J.L., Hoffman, M., Swaynigim, D.S.: Saline irrigation in gastric hemorrhage: the effect of temperature. J. Surg. Res.28:204, 1980

    Google Scholar 

  43. Athanasoulis, C.A., Baum, S., Waltman, A.C., Ring, E.J., Imbembo, A., Vander Salm, T.J.: Control of acute gastric mucosal hemorrhage: intra-arterial infusion of posterior pituitary extract. N. Engl. J. Med.290:597, 1974

    Google Scholar 

  44. Limberg, B., Kommerell, B.: Somatostatin after failure of cimetidine for acute bleeding ulcers, letter. Lancet2:1361, 1979

    Google Scholar 

  45. Williams, J.W., Pannell, W.P., Sherman, R.T.: Curling's ulcer in children. J. Trauma16:639, 1976

    Google Scholar 

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The opinions or assertions contained herein are the private view of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

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Pruitt, B.A., Goodwin, C.W. Stress ulcer disease in the burned patient. World J. Surg. 5, 209–220 (1981). https://doi.org/10.1007/BF01658293

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