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Treatment of established stress ulcer disease

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Abstract

All patients who are at risk of developing stress ulcers or who may have stress ulcers without hemorrhage should be treated with vigorous antacid therapy with or without cimetidine to prevent the deeper penetration of these erosions into the larger blood vessels of the submucosa. Bleeding from stress ulcers should be treated initially with iced saline lavage, since this maneuver serves to arrest hemorrhage in most patients. Replacement of blood, treatment of underlying sepsis, avoidance of gastric irritants such as aspirin, and correction of coagulation defects are all important parts of the management program. Endoscopy enables the positive identification of the lesions that are bleeding and provides an opportunity for direct control by electrocoagulation at institutions where this technique is available. Persistent bleeding from acute stress ulcers may be treated with intra-arterial infusion of vasopressin into the left gastric artery, if trained personnel are present. If all nonsurgical measures fail to control bleeding, then vagotomy, pyloroplasty, and suture ligation of the bleeding site should be performed. Rebleeding after this procedure will require a near total gastrectomy. Surgical mortality rate in these patients exceeds 30%, indicating the lethal nature of this complication and the seriousness of the underlying illness associated with stress ulcers. Therefore, one must combat ongoing illness, such as sepsis, as well as control the massive hemorrhage when established stress ulcer disease is present.

Résumé

Tout malade qui risque de développer un ulcère de stress, ou qui peut avoir une telle lésion sans hémorragie, doit être traité vigoureusement par des anti-acides avec ou sans cimétidine, pour prévenir l'aggravation des ulcères et le risque d'érosion des vaisseaux de la sous-muqueuse. Toute hémorragie sur ulcère de stress doit être traitée d'abord par des rinçages gastriques au sérum glacé: cette thérapeutique arrête l'hémorragie dans la majorité des cas. Le programme thérapeutique doit également viser à remplacer le sang perdu, à traiter l'infection, à éviter les irritants de la muqueuse gastrique comme l'aspirine et à corriger tout trouble de la coagulation. L'endoscopie permet de visualiser la ou les lésions qui saignent et de réaliser, si l'équipement existe dans l'institution, l'électrocoagulation qui contrôlera l'hémorragie. Si celle-ci persiste, elle peut être traitée par perfusion de vasopressine dans l'artère coronaire stomachique, si l'on dispose d'un personnel entraîné. En cas d'échec de toutes ces thérapeutiques non opératoires, il faut réaliser une vagotomie avec pyloroplastie et suture-ligature de la lésion saignante. Si le malade resaigne après cette intervention, il faut faire une gastrectomie presque totale. Chez ces patients, la mortalité opératoire dépasse 30%, ce qui démontre bien la gravité de cette complication et des affections qui en sont responsables. En cas d'ulcère de stress, il faut lutter contre la maladie causale, l'infection par exemple, en même temps qu'on traite l'hémorragie.

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Correspondence to Laurence Y. Cheung M.D..

Additional information

Supported by National Institute of Health Grant AM25998-01 and by the Medical Research Service of the Veterans Administration.

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Cheung, L.Y. Treatment of established stress ulcer disease. World J. Surg. 5, 235–239 (1981). https://doi.org/10.1007/BF01658299

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Keywords

  • Cimetidine
  • Stress Ulcer
  • Left Gastric Artery
  • Suture Ligation
  • Coagulation Defect