World Journal of Surgery

, Volume 5, Issue 2, pp 223–229 | Cite as

Methods of prophylaxis in stress ulcer disease

  • Hans -Joachim Priebe
  • John J. Skillman
Article

Abstract

Although infrequent, acute upper gastrointestinal bleeding is potentially life-threatening for critically ill patients. Gastric erosions can be detected endoscopically in almost all seriously ill patients. Although gastric acid plays a key role in the pathogenesis of acute gastric erosions, mucosal integrity is very much dependent on mucosal permeability, gastric blood flow, the secretory state of the mucosa, and acid-base balance. Various agents that affect any of these physiological processes such as vitamin A, carbenoxolone, gastrin, vasoactive agents, sodium bicarbonate, and anticholinergic drugs have been used experimentally or clinically in the prevention of stress ulcerations. However, no controlled clinical trials are available. The effectiveness of antacids in the prevention of acute stress ulceration in critically ill patients has been documented in controlled, prospective trials. The effectiveness of the histamine H2-receptor antagonist cimetidine remains controversial; it is less effective in critically ill patients of the type usually encountered in a respiratory-surgical intensive care unit but it may be effective in selected groups of patients with head and thermal injury. Prostaglandins have been evaluated increasingly for their cytoprotective effects on the gastric mucosa. Clinical trials are needed to evaluate their effectiveness in the prevention of stress ulcers.

Résumé

Chez le malade en état grave, les hémorragies digestives hautes aiguës sont rares mais sont menaçantes. Les érosions gastriques peuvent presque toujours être mises en évidence par endoscopie chez ces patients. Bien que l'acidité gastrique joue un rôle important dans la pathogénie des ulcérations gastriques aiguës, l'intégrité de la muqueuse dépend beaucoup de sa perméabilité, du débit sanguin gastrique, de l'état sécrétoire de la muqueuse et de l'équilibre acide-base. De nombreux médicaments qui agissent sur ces mécanismes physiologiques ont été utilisés, en expérimentation et en clinique, pour prévenir les ulcérations de stress: vitamine A, carbenoxolone, gastrine, médicaments vaso-actifs, bicarbonate de soude, anticholinergiques. Il n'existe cependant à l'heure actuelle, aucune étude clinique contrôlée qui soit valable. L'efficacité des anti-acides dans la prévention des ulcères de stress aigus chez le malade grave a été démontrée par des essais prospectifs contrôlés. L'utilité de la cimétidine, antagoniste des récepteurs H2, reste controversée; elle parait peu efficace chez le type de malades que l'on hospitalise en général dans les unités de soins intensifs respiratoires chirurgicales; elle est peut-être utile dans des groupes sélectionnés de patients atteints de lésions crânio-encéphaliques et de brûlures. Les études sur les effets cytoprotecteurs des prostaglandines sur la muqueuse gastrique sont de plus en plus nombreuses. Des essais cliniques sont encore nécessaires pour tester leur efficacité dans la prévention des ulcères de stress.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Skillman, J.J., Bushnell, L.S., Goldman, H., Silen, W.: Respiratory failure, hypotension, sepsis and jaundice: a clinical syndrome associated with lethal hemorrhage from acute stress ulceration of the stomach. Am. J. Surg.117:523, 1969Google Scholar
  2. 2.
    Lucas, C.E., Sugawa, C., Riddle, J., Rector, F., Rosenberg, B., Walt, A.J.: Natural history and surgical dilemma of “stress” gastric bleeding. Arch. Surg.102:266, 1971Google Scholar
  3. 3.
    Skillman, J.J., Gould, S.A., Chung, R.S.K., Silen, W.: The gastric mucosal barrier: clinical and experimental studies in critically ill and normal man, and in the rabbit. Ann. Surg.172:564, 1970Google Scholar
  4. 4.
    Beil, A.R., Jr., Mannix, H., Jr., Beal, J.M.: Massive gastrointestinal hemorrhage after operation. Am. J. Surg.108:324, 1964Google Scholar
  5. 5.
    Czaja, A.J., McAlhany, J.S., Pruitt, B.A., Jr.: Acute gastroduodenal disease after thermal injury: an endoscopic evaluation of incidence and natural history. N. Engl. J.Med.291:925, 1974Google Scholar
  6. 6.
    Fogelman, M.J., Garvey, J.M.: Acute gastrointestinal ulceration incident to surgery and disease: analysis and review of eighty-eight cases. Am. J. Surg.112:651, 1966Google Scholar
  7. 7.
    Moody, F.G., Aldrete, J.S.: Hydrogen permeability of canine gastric secretory epithelium during formation of acute superficial erosions. Surgery70:154, 1971Google Scholar
  8. 8.
    Kivilaakso, E., Silen, W.: Pathogenesis of experimental gastric mucosal injury. N. Engl. J. Med.301:364, 1979Google Scholar
  9. 9.
    Hamza, K.N., DenBesten, L.: Bile salts producing stress ulcers during experimental shock. Surgery71:161, 1972Google Scholar
  10. 10.
    Kim, Y., Kerr, R.J., Lipkin, M.: Cell proliferation during the development of stress erosions in the mouse stomach. Nature215:1180, 1967Google Scholar
  11. 11.
    Crean, G.P.: The endocrine system and the stomach. Vitam. Horm.21:215, 1963Google Scholar
  12. 12.
    Jacobson, E.D., Magnani, T.J.: Some effects of hypophysectomy on gastrointestinal function and structure. Gut5:473, 1964Google Scholar
  13. 13.
    Vanamee, P., Winawer, S.J., Sherlock, P.: Decreased incidence of restraint-stress induced gastric erosions in rats treated with bovine growth hormone. Proc. Soc. Exp. Biol. Med.135:259, 1970Google Scholar
  14. 14.
    Chernov, M., Hale, M., Wood, M.: Prevention of stress ulcers. Am. J. Surg.161:977, 1965Google Scholar
  15. 15.
    Martin, M.S., Lambert, R., Martin, F., André, C.: Effect protecteur de la vitamine A sur l'ulcere de contrainte du rat. C. R. Soc. Biol. (Paris)161:2527, 1967Google Scholar
  16. 16.
    Ozdemir, A., Zimmerman, B.: The effect of adrenalectomy and endocrine substances on restraint-induced acute gastric ulceration. Surg. Forum21:304, 1970Google Scholar
  17. 17.
    Rasche, R., Butterfield, W.C.: Vitamin A pretreatment of stress ulcers in rats. Arch. Surg.106:320, 1973Google Scholar
  18. 18.
    Strauss, R.J., Stein, T., Mandell, C., Wise, L.: Prevention of stress ulcerations with cimetidine and carbenoxolone. Surg. Forum28:361, 1977Google Scholar
  19. 19.
    Takeuchi, K., Johnson, L.R.: Pentagastrin protects against stress ulceration in rats. Gastroenterology76:327, 1979Google Scholar
  20. 20.
    Johnson, L.R.: The trophic action of gastrointestinal hormones. Gastroenterology70:278, 1976Google Scholar
  21. 21.
    Hartman, F.W.: Curling's ulcer in experimental burns. II. The effect of penicillin therapy. Ann. Surg.121:54, 1945Google Scholar
  22. 22.
    Rosoff, C.B., Goldman, H.: Effect of the intestinal flora on acute gastric stress ulceration. Gastroenterology55:212, 1968Google Scholar
  23. 23.
    Nance, F.C., Kaufman, H.J., Batson, R.C.: The role of the microbial flora in acute gastric ulceration. Surgery72:68, 1972Google Scholar
  24. 24.
    Ritchie, W.P., Jr., Roth, R.R., Fisher, R.P.: Studies on the pathogenesis of “stress ulcer”: effect of hemorrhage, transfusion, and vagotomy in the restrained rat. Surgery71:445, 1972Google Scholar
  25. 25.
    Ritchie, W.P. Jr., Shearburn, E.W., III: Influences of isoproterenol and cholestyramine on acute gastric mucosal ulcerogenesis. Gastroenterology73:62, 1977Google Scholar
  26. 26.
    Brodie, D.A., Valitski, L.S.: Production of gastric hemorrhage in rats by multiple stresses. Proc. Soc. Exp. Biol. Med.113:998, 1963Google Scholar
  27. 27.
    Okabe, S., Saziki, R., Tahagi, K.: Effects of adrenergic blocking agents on gastric secretion and stressinduced gastric ulcer in rats. Jpn. J. Pharmacol.20:10, 1970Google Scholar
  28. 28.
    Nicoloff, D.M.: Effect of cathecolamines on gastric secretion and blood flow. Ann. Surg.159:32, 1964Google Scholar
  29. 29.
    Djahanguiri, B., Taubin, H., Landsberg, L.: Increased sympathetic activity in the pathogenesis of restraint ulcers in rats. J. Pharmacol. Exp. Ther.184:163, 1973Google Scholar
  30. 30.
    Sethbhakdi, S., Pfeiffer, C.J., Roth, J.L.A.: Gastric mucosal ulceration following vasoactive agents. A new experimental model. Dig. Dis. Sci.15:261, 1970Google Scholar
  31. 31.
    Sethbhakdi, S., Roth, J.L.A., Pfeiffer, C.J.: Gastric mucosal ulceration after epinephrine—a study of etiological mechanisms. Dig. Dis. Sci.15:1055, 1970Google Scholar
  32. 32.
    Davies, R.E., Longmuir, N.M.: Production of ulcers in isolated frog gastric mucosa. Biochem. J.42:621, 1948Google Scholar
  33. 33.
    Cummins, G.M., Grossman, M.I., Ivy, A.C.: An experimental study of the acid factor in ulceration of the gastrointestinal tract in dogs. Gastroenterology10:714, 1948Google Scholar
  34. 34.
    Mersereau, W.A., Hinchey, E.J.: Effect of gastric acidity on gastric ulceration induced by hemorrhage in the rat, utilizing a gastric chamber technique. Gastroenterology64:1130, 1973Google Scholar
  35. 35.
    Ritchie, W.P., Jr.: Acute gastric mucosal damage induced by bile salts, acid, and ischemia. Gastroenterology68:699, 1975Google Scholar
  36. 36.
    Kivilaakso, E., Fromm, D., Silen, W.: Relationship between ulceration and intramural pH of gastric mucosa during hemorrhagic shock. Surgery84:70, 1978Google Scholar
  37. 37.
    Foss, D.L., Stavney, L.S., Haraguchi, T., Harkins, H.: Pathophysiologic and therapeutic considerations of Curling's ulcer in the rat. J.A.M.A.187:592, 1964Google Scholar
  38. 38.
    Watts, C.C., Clark, K.: Gastric acidity in the comatose patient. J. Neurosurg.30:107, 1969Google Scholar
  39. 39.
    Watts, C.C., Clark, K.: Effects of an anticholinergic drug on acid secretion in the comatose patient. Surg. Gynecol. Obstet.130:61, 1970Google Scholar
  40. 40.
    Hastings, P.R., Skillman, J.J., Bushnell, L.S., Silen, W.: Antacid titration in the prevention of acute gastrointestinal bleeding. A controlled, randomized trial in 100 critically ill patients. N. Engl. J. Med.298:1041, 1978Google Scholar
  41. 41.
    McAlhany, J.C., Czaja, A.J., Pruitt, B.: Antacid control of complications from acute gastroduodenal disease after burns. J. Trauma16:645, 1976Google Scholar
  42. 42.
    Curtis, L.E., Simonian, S., Buerk, C.A., Hirsch, E.F., Soroff, H.S.: Evaluation of the effectiveness of controlled pH in management of massive upper gastrointestinal bleeding. Am. J. Surg.125:474, 1973Google Scholar
  43. 43.
    Simonian, S.J., Curtis, L.E.: Treatment of hemorrhagic gastritis by antacid. Ann. Surg.184:429, 1976Google Scholar
  44. 44.
    MacDougal, B.R.D., Bailey, R.J., Williams, R.: H2receptor antagonists and antacids in the prevention of acute gastrointestinal hemorrhage in fulminant hepatic failure. Two controlled trials. Lancet1:617, 1977Google Scholar
  45. 45.
    Safaie-Shirazi, S., Foster, L.D., Hardy, B.M.: The effect of metiamide, an H2-receptor antagonist, in the prevention of experimental stress ulcers. Gastroenterology71:421, 1976Google Scholar
  46. 46.
    Levine, B.A., Sirinek, K.R., Pruitt, B.A.: Cimetidine protects against stress-induced gastric injury augmented by mucosal barrier breakers. Am. J. Surg.137:328, 1979Google Scholar
  47. 47.
    MacDonald, A.S., Steele, B.J., Bottomley, M.G.: Treatment of stress-induced upper gastrointestinal hemorrhage with metiamide. Lancet1:68, 1976Google Scholar
  48. 48.
    Priebe, H.J., Skillman, J.J., Bushnell, L.S., Long, P.C., Silen, W.: Antacid versus cimetidine in preventing acute gastrointestinal bleeding. N. Engl. J. Med.302:426, 1980Google Scholar
  49. 49.
    Jones, R.H., Rudge, C.J., Bewick, M., Parsons, V., Weston, M.J.: Cimetidine: prophylaxis against upper gastrointestinal hemorrhage after renal transplantation. Br. Med. J.1:398, 1978Google Scholar
  50. 50.
    Dunn, D.H., Fischer, R.C., Silvis, S.E., Onstad, G.R., Howard, R.J., Delaney, J.P.: The treatment of hemorrhagic gastritis with cimetidine. Surg. Gynecol. Obstet.147:737, 1978Google Scholar
  51. 51.
    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, 1979Google Scholar
  52. 52.
    Halloran, L.G., Zfass, A.M., Gayle, W.E., Wheeler, C.B., Miller, J.D.: Prevention of acute gastrointestinal complications after severe head injury: a controlled trial of cimetidine prophylaxis. Am. J. Surg.139:44, 1980Google Scholar
  53. 53.
    Kivilaakso, E., Fromm, D., Silen, W.: Effect of the acid secretory state on intramural pH of rabbit gastric mucosa. Gastroenterology75:641, 1978Google Scholar
  54. 54.
    Smith, P., O'Brien, P., Fromm, D., Silen, W.: Secretory state of gastric mucosa and resistance to injury by exogenous acid. Am. J. Surg.133:81, 1977Google Scholar
  55. 55.
    Carmichael, H.A., Nelson, L.M., Russell, R.T.: Cimetidine and prostaglandin: evidence for different modes of action on the rat gastric mucosa. Gastroenterology74:1229, 1978Google Scholar
  56. 56.
    Cohen, M.M.: Mucosal cytoprotection by prostaglandin E2. Lancet2:1253, 1978Google Scholar
  57. 57.
    Robert, A., Nezamis, J.E., Lancaster, C., Hanchar, A.J.: Cytoprotection by prostaglandins in rats: prevention of gastric necrosis produced by alcohol, HCl, NaOH, hypertonic NaCl and thermal injury. Gastroenterology77:433, 1979Google Scholar
  58. 58.
    Miller, T., Jacobson, E.D.: Progress report. Gastrointestinal cytoprotection by prostaglandins. Gut20:75, 1979Google Scholar

Copyright information

© Société Internationale de Chirurgie 1981

Authors and Affiliations

  • Hans -Joachim Priebe
    • 1
  • John J. Skillman
    • 1
  1. 1.Departments of Anaesthesia and SurgeryHarvard Medical School and Beth Israel HospitalBostonUSA

Personalised recommendations