Patients suffering from shock, sepsis, massive burns, severe trauma and head injury can develop acute erosive mucosal damage and ulceration.
Stress-related mucosal injury is mostly seen in the acid-producing portions of the stomach, the fundus and body. In most cases the bleeding is very minimal, but it can occasionally be life-threatening.
The risk factors for bleeding from stress-related mucosal injury are mechanical ventilation and underlying bleeding disorders.
Different causes of stress-related mucosal injury produce injury through different mechanisms. A Cushing ulcer, occurring in head injuries, and a Curling ulcer, occurring in severe burns, both arise from higher acid production. Sepsis acts through the systemic release of cytokines, and shock acts through ischaemia of the protective barrier.
During the last years, thanks to better ICU management of critically ill patients, the incidence of gastrointestinal bleeding has decreased from 20–30% to less than 5%. The high mortality of gastrointestinal bleeding in critically ill patients, about 40%, and the limited benefit of clinical and surgical interventions in haemodynamically compromising bleeding, have forced the use of preventive treatment for gastrointestinal bleeding due to stress-induced injury in certain patients (stress prophylaxis):
- mechanically ventilated patients;
- patients with coagulopathy;
- patients with multi-organ failure;
- patients with severe burns.