What is Curling Ulcer?
Stress ulcers refer to a type of gastritis or stomach lining inflammation triggered by high-levels of stress or severe illness. These ulcers occur when there’s a disruption in the protective lining of the stomach, sometimes also affecting the esophagus or upper part of the small intestine. This condition can take various forms – from unnoticeable superficial marks and hidden gastrointestinal (GI) bleeding, to noticeable and significant GI bleeding. Stress ulcers linked to severe burns are called Curling ulcers, while those connected with serious brain injuries are known as Cushing ulcers. Although these ulcers commonly appear in the stomach’s body and upper part, they can also arise in the lower part of the stomach and in the duodenum, the first section of the small intestine.
What Causes Curling Ulcer?
Stress ulcers can develop due to a number of risk factors:
1. Being on a ventilator for over 48 hours.
2. Having abnormal blood clotting, such as a low platelet count (less than 50,000), a higher INR (International Normalized Ratio) than 1.5, and a PTT (Partial Thromboplastin Time) greater than twice the normal value.
3. Experiencing sepsis or shock caused by an infection.
4. Using vasopressors, medications that constrict blood vessels and increase blood pressure.
5. Taking high doses of systemic corticosteroids (over 250 mg or the equivalent amount of hydrocortisone per day).
6. Suffering from liver or kidney failure.
7. Having multiple organ failures.
8. Having over 30% of body surface area affected by burns.
9. Experiencing severe head trauma.
10. Not maintaining adequate cleanliness during an intensive care unit (ICU) stay.
11. Having a history of gastrointestinal bleeding within the past year.
These are the primary conditions that can increase the likelihood of getting stress ulcers.
Risk Factors and Frequency for Curling Ulcer
Stress ulcers usually develop in people battling severe acute illnesses, although the exact frequency is uncertain. Upper digestive tract bleeding is the most common sign of these ulcers. The percentage of patients who bleed due to stress ulcers varies between 1.5% and 15% and largely relies on whether they’ve received preventative treatment for stress ulcers. Thankfully, now that there are effective ways to prevent stress-related gastritis, the occurrence of stress ulcers and their complications has decreased. However, patients who bleed as a result of stress ulcers tend to have more health issues and a higher risk of death than those who do not have such bleeding. Consequently, many scientific studies have focused on methods to prevent stress ulcers. In very rare cases (less than 1% of the time), stress ulcers can break open, leading to other complications.
Signs and Symptoms of Curling Ulcer
Stress ulcers usually show up as a sudden bleed in the upper part of the digestive tract. This can result in vomiting blood or passing black, tarry stools. The patient might not always show signs of low blood pressure, despite the bleeding. Often though, these episodes cause a decrease in red blood cell count, which might require blood transfusions.
It’s essential for healthcare providers to be alert to this possibility, especially in patients in the intensive care unit who are found to have a lower-than-normal red blood cell count. Common symptoms of stress ulcers include:
- Vomiting material that looks like coffee grounds
- Vomiting blood
- Black, tarry stools
- Stomach pain
- Feeling nauseous
- Dizziness when standing up (in severe cases)
Testing for Curling Ulcer
Before checking for stress-induced ulcers, it’s most important to stabilize the patient. This could involve monitoring whether they need extra fluids or blood transfusion, and possibly treating blood-clotting issues. A procedure called gastric lavage might also be used. This helps the doctors determine if there’s any blood in the upper part of the digestive system. It can also measure the quantity of blood, if found.
A test called an esophagogastroduodenoscopy can also be performed. This can identify stress ulcers, which appear as small, shallow breaks or ulcers in the stomach’s lining. Tests for an infection called H. pylori, such as a urease breath test or a stool antigen test, can be used if the stress ulcer is difficult to treat.
Treatment Options for Curling Ulcer
Managing stress-induced gastritis involves quick recognition and taking preventive steps to avoid complications related to stress ulcers. The management is split into medication-based treatments and non-drug treatments.
Without using medicines, interventions could be providing nutrition through feeding tubes, placing a tube in the stomach for draining, reviving with intravenous fluids, blood transfusion, and restoring normal blood clotting through platelet transfusion or adding fresh frozen plasma or a blood product called cryoprecipitate.
The medical approach for patients with stress ulcers is quite similar to the overall approach for peptic ulcer diseases. The medicines aimed at treating acid peptic disease include proton pump inhibitors, antihistamines, and ulcer-healing drugs like sucralfate. If a patient shows clear signs of gastrointestinal bleeding from ulcers, an endoscope (a flexible tube with a camera) may be used to evaluate and manage the stress ulcers. The treatments using an endoscope can involve injecting epinephrine, using an electric current to stop bleeding, or placing a clip on the bleeding blood vessels. If the bleeding doesn’t stop with these local endoscopic treatments, they might need to block the bleeding blood vessel or, in rare cases, undergo surgery as a last option. Surgery is often considered for patients who keep bleeding despite endoscopic or angiographic treatments or for those too unstable to undergo endoscopy or angiography. Surgeries are performed as the ultimate way to save lives.
Occasionally, the ulcers can be deep enough to make a hole in the gastric wall, leading to a condition called acute peritonitis, which requires emergency surgery. Compared to other types of stress ulcerations, perforations are most likely with Cushing and Curling ulcers as they tend to be deep and can cause extensive tissue death. Without surgical intervention, almost all patients with free wall GI perforation (a hole in the gastrointestinal wall) have a risk of dying.
What else can Curling Ulcer be?
When trying to diagnose a specific condition, doctors may also consider the following potential causes:
- Stomach ulcers (peptic ulcer disease)
- Stomach irritation caused by certain pain relievers (NSAID-induced gastritis)
- Stomach damage from alcohol use (alcoholic gastropathy)
- Acid reflux (GERD)
- Stomach or throat cancer (gastric or esophageal cancer)
- Slowed stomach emptying (gastroparesis)
- Pancreatic cancer
- Pain related to the gallbladder or bile ducts (biliary pain)
- Stomach issues due to kidney disease (uremic gastropathy)
- General stomach discomfort (dyspepsia)
Each of these conditions could potentially cause similar symptoms, so it’s essential for the doctor to investigate further to give an accurate diagnosis.
What to expect with Curling Ulcer
People who have stress ulcers usually face poor health outcomes due to their existing serious illness. To make matters worse, these individuals can suffer from GI bleeds due to stress-related mucosal disease, which often leads to even more health issues and a higher risk of death. These patients are usually in such a dire state that they can’t undergo advanced procedures to control GI bleeding, resulting in worse outcomes.
Because of this, it’s crucial to be proactive in preventing stress ulcers among patients at risk. This preventive measure is the key part of managing stress-induced gastropathy.
Possible Complications When Diagnosed with Curling Ulcer
Stress ulcers can come with a range of complications, such as:
- Bleeding
- Anemia
- Strictures, which are abnormal narrowing of a body passage
- Perforation, or a hole in the organ
- Peritonitis, which is inflammation of the tissue that lines the inner wall of the abdomen
- Gastrocolic fistula, or abnormal connections between the stomach and the colon
- Gastric outlet obstruction due to strictures which can block the passage of food out of the stomach
- Hemorrhagic shock, a severe and potentially deadly loss of blood
- Increased length of stay in the ICU (Intensive Care Unit)
- Death
Preventing Curling Ulcer
Stress ulcers are essentially sores that develop in your digestive system and can upset your stomach, even causing bleeding. These ulcers can make you feel discomfort in the upper part of your abdomen, as well as cause feelings of nausea, vomiting or even see blood in your stool. The ulcers occur when your body experiences high levels of stress, leading to an overproduction of acid. This excess acid breaks down the mucus layer that usually protects your stomach lining, leaving it vulnerable to damage. However, preventive measures in places like intensive care units can significantly reduce the chances of these ulcers coming back. If you ever have concerns about stress ulcers, your best course of action would be to consult with healthcare professionals for information and advice.
