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Cushing Ulcer

Ulcer Cushing's

Cushing ulcer is an acute gastro-duodenal ulcer that can develop within hours of a traumatic brain injury. The pathology is debated. Explanations include acid damage resulting from increased parietal cell activity mediated by the vagus nerve, and a decrease in protective mucus production. These days, the condition is efficiently prevented in critically ill patients by decreasing acid production with antacids and histamine-2 receptor blockers.


Presentation

Cushing ulcer, which can form in the stomach, duodenum, or esophagus, is a complication of traumatic brain injuries. It develops very quickly (possibly within hours) following trauma. It is often discussed in the context of stress ulcers [1] and manifestations of stress gastritis (originally called neurogenic gastritis), but it has some characteristics not shared by other stress ulcers. Stress ulcers in general manifest as a number of superficial lesions in the gastric mucosa, whereas Cushing ulcer is usually solitary and deep, and therefore carries a high risk of perforation. Another distinguishing feature of Cushing ulcers is that it is associated with increased levels of gastrin and pepsin [2]. The pathophysiology of the condition is not completely clear but is likely to be due to the effects of elevated intracranial pressure following brain injury [1] with consequent increased gastric acid production due to stimulation of the vagus nerve [3].

The three patients described in the original 1932 paper of Cushing [4] [5] had cerebellar tumors and died after surgery due to perforative peritonitis. They had symptoms of bloating and abdominal sensitivity, or severe abdominal pain, or brown vomit. The occurrence of ulcers in patients with an intracranial disease was observed almost a century earlier by Rokitansky, hence the disease is often referred to as Rokitansky-Cushing ulcer. Presentation with sudden fever, leukocytosis, and volume contraction in the presence of increased intracranial pressure and high-dose corticosteroid administration were suggested as diagnostic clues for perforated stress ulcer by Walsh et al. [6] for aphasic patients. The lesions have about a 17% risk of bleeding [1] [7].

Acute stress gastritis following brain injury has been on the decline since the introduction of prophylaxis using antacids and histamine-2 receptor antagonists [4] [8]. Nevertheless, the condition still occurs for various reasons, one of which is a large number of head injuries due to traffic accidents [1]. Cushing ulcer sometimes develops in spite of ulcer prophylaxis, as in the case of an 8-month old infant with medulloblastoma who became afflicted with the condition once a preoperative dexamethasone treatment was initiated [9].

Hunting
  • McGraw-Hill, New York, ‎ Pagina 432 - Knighton DR, Hunt TK, Scheuenstuhl H, Halliday BJ, Werb Z, Banda MJ (1983) Oxygen tension regulates the expression of angiogenesis factor by macrophages.[books.google.it]
  • Huang JQ, Sridhar S, Hunt RH. Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in pepticulcer disease: a meta-analysis. Lancet. 2002;359:14–22. 11. Graham DY.[aafp.org]
Buffalo Hump
  • MOODIAH M- moon face,buffalo hump O- osteoporosis O- obesity and oedema from Na & H2O retension D- diabetes I- infections A- atherosclerosis H- hypertension, hirsutism A Cushing ulcer is a gastric ulcer produced by elevated intracranial pressure.[notesmedical.blogspot.com]
Hemoptysis
  • Mechanism of Cushing ulcer We infer from his history of several months of melena and hemoptysis that our patient likely developed duodenal ulcers secondary to increased intracranial pressure from the medulloblastoma obstructing cerebrospinal fluid outflow[tp.amegroups.com]
Abdominal Pain
  • Aortic Dissection 207 Abdominal Aortic Aneurysm AAA 208 ObstetricGynecologic Causes of Acute Abdominal Pain 209 Urologic Causes of Acute Abdominal Pain 210 Abdominal Pain in Pediatric Populations 211 Nonsurgical Causes of Abdominal Pain 212 Review Test[books.google.com]
  • They had symptoms of bloating and abdominal sensitivity, or severe abdominal pain, or brown vomit.[symptoma.com]
  • It should be considered in upper abdominal pain presenting with UGI bleeding especially when there is a history of liver injury or instrumentation. First recorded in 1654 by Francis Glisson, a Cambridge professor.[howlingpixel.com]
  • Absence of abdominal pain in older persons with endoscopic ulcers: a prospective study. Am J Gastroenterol. 2001;96:380–4. 17. Martinez JP, Mattu A. Abdominal pain in the elderly. Emerg Med Clin North Am. 2006;24:371–88. 18. Hassall E.[aafp.org]
Melena
  • Upon further questioning, the family reported 3 months of occasional coffee-ground emesis and melena prior to admission. There was no history of burn, sepsis, major trauma, or prior medication ingestion.[tp.amegroups.com]
  • Weight loss may occur Pain occurs 1 2 to 1 hour after a meal may be relieved by vomiting; ingestion of food does not help, sometimes increases pain Vomiting common Hemorrhage more likely to occur than with duodenal ulcer; hematemesis more common than melena[nsgmed.com]
  • Pain relieved by eating Night pain morning relief periodicity Sharply localized tenderness in the epigastrium slightly to the right of the midline Heartburn (pyrosis) Vomiting Constipation Diarroea Bleeding Melena (altered blood in the stool) black tarry[examnnotes.com]
  • Anamnesis revealed, among other symptoms, weakness, easy fatigue, and melena in the previous few days. For the last 7 days, he took doxycycline ordered by a general practitioner because of pharyngitis.[karger.com]
  • […] duodenal ulcer; hematemesis more common than melena 24.[slideshare.net]
Hematemesis
  • […] and Clinical Findings Hypersecretion of stomach acid (HCl) May have weight gain Pain occurs 2–3 hours after a meal ingestion of food relieves pain Vomiting uncommon Hemorrhage less likely than with gastric ulcer, but if present melena more common than hematemesis[nsgmed.com]
  • […] duodenal ulcer; hematemesis more common than melena 24.[slideshare.net]
  • Pathophysiology Clinical features Gastric ulcer Duodenal ulcer Findings common to both Dyspepsia : postprandial heaviness, early satiety, and gnawing, aching or burning epigastric pain Pain relief with antacids Potential signs of internal bleeding ( anemia, hematemesis[amboss.com]
  • […] pseudomembrane Sx 1 Esophagitis (HSV-1) Punched out ulcers Sx 1 Esophagitis (CMV) Linear ulcers Sx 1 Esophagitis Reflux/infection/chemical ingestion Etio 3 Mallory-Weiss Syndrome Alcoholism/bulemia/mucosal lacerations from vomiting Etio 3 Mallory-Weiss Syndrome Hematemesis[memorize.com]
Gastropathy
  • Introduction Stress ulcers is a well-known clinical entity described as stress-induced gastritis or gastropathy where the gastric and sometimes esophageal or duodenal mucosal barrier is disrupted secondary to a severe acute illness.[ncbi.nlm.nih.gov]
  • […] aggressive - 5HT, sub P, polypeptide YY 25% Appendix (only one that affects "young") - 5HT, polypeptide YY 25% Colorectal - 5HT, polypeptide YY) In body or fundus 5HT Somatostatin Histamine Sx Gastritis Ulcer aSx Assoc Atrophic gastritis MEN-I HYPERTROPHIC GASTROPATHY[alancam.com]
  • Additional etiologic factors Any of the following may be associated with PUD: Hepatic cirrhosis Chronic obstructive pulmonary disease Allergic gastritis and eosinophilic gastritis Uremic gastropathy Henoch-Schönlein gastritis Corrosive gastropathy Bile[emedicine.medscape.com]
Black Stools
  • Emergency Symptoms A person who has any of the following symptoms should call a doctor right away: sharp, sudden, persistent, and severe stomach pain bloody or black stools bloody vomit or vomit that looks like coffee grounds These “alarm” symptoms could[nsgmed.com]
Oral Ulcers
  • Mr. m answers : " it is said that there are 300 or 400 kinds of oral microorganisms. they multiply and cause not only halitosis but also gums bleeding, gingivitis, periodontits, tooth decay and oral ulcer. when it becomes serious it can lead to pulpitis[dict.site]
Periodontitis
  • " it is said that there are 300 or 400 kinds of oral microorganisms. they multiply and cause not only halitosis but also gums bleeding, gingivitis, periodontits, tooth decay and oral ulcer. when it becomes serious it can lead to pulpitis, periapical periodontitis[dict.site]
Halitosis
  • Mr. m answers : " it is said that there are 300 or 400 kinds of oral microorganisms. they multiply and cause not only halitosis but also gums bleeding, gingivitis, periodontits, tooth decay and oral ulcer. when it becomes serious it can lead to pulpitis[dict.site]
Photophobia
Osteoporosis
  • MOODIAH M- moon face,buffalo hump O- osteoporosis O- obesity and oedema from Na & H2O retension D- diabetes I- infections A- atherosclerosis H- hypertension, hirsutism A Cushing ulcer is a gastric ulcer produced by elevated intracranial pressure.[notesmedical.blogspot.com]
Lethargy
  • An 8-month-old boy presented with progressive vomiting, lethargy, and decreased oral intake. Imaging revealed a heterogeneous fourth ventricular mass. Preoperatively, the patient was started on dexamethasone.[sparrho.com]
  • Case presentation History and examination An 8-month-old boy conceived via in-vitro fertilization presented to our institution with 10 days of progressive vomiting, lethargy, and decreased oral intake.[tp.amegroups.com]

Workup

Perforation of a Cushing ulcer should be anticipated in patients with brain injuries [6].

Upper gastrointestinal endoscopy is the most sensitive technique for the detection of gastric and duodenal ulcers. Endoscopy can also be used to obtain biopsy samples for cytological examination, or for testing for Helicobacter pylori infection. Radiography is useful for the detection of free air in the abdomen, an indication of perforation; however, the absence of free air does not exclude the possibility of perforation [6]. Angiography is used in patients who have massive bleeds. Various laboratory parameters are performed, for example, serum gastrin levels.

Periostal Elevation
  • Synonym(s): Cushing pituitary basophilism Cushing dressing forceps Cushing dural hook Cushing dural hook knife Cushing Gigli-saw guide Cushing nerve retractor Cushing perforator Cushing perforator drill Cushing periosteal elevator Cushing phenomenon -[medical-dictionary.thefreedictionary.com]
Foam Cell
  • Cholesterolosis results from abnormal deposits of cholesterol esters in macrophages within the lamina propria (foam cells) and in mucosal epithelium. The gallbladder may be affected in a patchy localized form or in a diffuse form.[howlingpixel.com]

Treatment

  • Most episodes of Cushing ulceration resolve on medical intervention, consisting primarily of rinsing the area with saline and the administration of antacids.Patients should also be put on proton pump inhibitors during the course of treatment until their[en.wikipedia.org]
  • Please consult your own licensed physician regarding diagnosis and treatment of any medical condition! Please see also our disclaimer. This site complies with the HONcode standard for health information: verify here. Database updated 2019-02-19.[diseasesdatabase.com]
  • […] of rinsing the area with saline and the administration of antacids. [4] Patients should also be put on proton pump inhibitors during the course of treatment until their intracranial pressure lowers to a normal level [ ].[popflock.com]
  • "Pathogenesis, diagnosis and treatment of acute gastric mucosal lesions". Clinics in Gastroenterology. 13 (2). ISSN 0300-5089.[howlingpixel.com]
  • Cushing ulcer sometimes develops in spite of ulcer prophylaxis, as in the case of an 8-month old infant with medulloblastoma who became afflicted with the condition once a preoperative dexamethasone treatment was initiated.[symptoma.com]

Prognosis

  • Prognosis Untreated CD can be life-threatening. The documents contained in this web site are presented for information purposes only.[orpha.net]
  • […] lymphoma: B-cell Metastases are rare Associated with paraproteins and pseudohyponatraemia H.Pylori eradication leads to regression in 80% Gastric cancer: VacA and CagA strains of H pylori appear to be associated with an increased risk of gastric cancer Prognosis[oxfordmedicaleducation.com]
  • Prognosis Patients with stress ulceration usually have poor prognosis secondary to the underlying critical illness.[ncbi.nlm.nih.gov]
  • […] radiograph Vital signs evidence of shock (hypotension/tachycardia despite fluid resuscitation) evidence of increasing intracranial pressure Cushing's triad: hypertension, bradycardia, irregular respirations rare - if all three present, suggests poor prognosis[medbullets.com]
  • . - if hard to distinguish, better prognosis if Ca -- 50-75% cure chance. Biopsy should be taken at the same time for H pylori. - Ideally 7 bx (10 good) and brush biopsy. - False ve rare, false -ve in 5-10%.[gog.net.nz]

Etiology

  • Etiology Risk factors Chronic gastritis caused by H. pylori, a curved, flagellated gram-negative rod Duodenal ulcers : up to 90% are due to H. pylori infection Gastric ulcers : up to 80% are due to H. pylori infection Chronic gastritis of other etiology[amboss.com]
  • In all other etiologic factors, gastric acid secretion is normal or below normal. 2. Chronic Peptic ulcer Treatment : Peptic ulcers can be treated by medications in following way : 1.[doctoralerts.com]
  • This is the most common etiology of type 3 ulcers, or prepyloric ulcers. Further Reading Peptic Ulcer - What are Peptic Ulcers? Peptic Ulcer Symptoms Peptic Ulcer Diagnosis Living with Peptic Ulcer Disease Peptic Ulcer Treatments[news-medical.net]
  • Etiology Little is known about the underlying pathogenesis of pituitary tumors.[orpha.net]
  • Etiology The major risk factors for the development of stress ulcerations include: Mechanical ventilation for more than 48 hours Abnormal coagulation profile such as platelet count less than 50,000, INR greater than 1.5 and PTT greater than 2 times the[ncbi.nlm.nih.gov]

Epidemiology

  • Duodenal ulcers 4 x more common than gastric ulcers Epidemiology of H.pylori Prevalence approximately 30% young adults Much higher in older people Causes of peptic ulcer disease H.[oxfordmedicaleducation.com]
  • Epidemiology References: [1] [2] [3] [4] [5] Epidemiological data refers to the US, unless otherwise specified.[amboss.com]
  • Summary Epidemiology Exact prevalence is unknown. Prevalence of endogenous CS is estimated at around 1/26,000, with CD representing more than two-thirds of all cases. Recent data suggests that mild CD is more common than previously thought.[orpha.net]
  • […] steroids (more than 250 mg or the equivalent) Hepatic failure Renal failure Multi-organ failure Burn more than 30% of body surface area Head trauma Lack of sanitation during intensive care unit (ICU) stay History of GI bleeds within a year [3] [4] [5] Epidemiology[ncbi.nlm.nih.gov]
  • Lau JY, Sung J, Hill C, Henderson C, Howden CW, Metz DC: Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion 2011;84:102-113.[karger.com]
Sex distribution
Age distribution

Pathophysiology

  • The pathophysiology of the condition is not completely clear but is likely to be due to the effects of elevated intracranial pressure following brain injury with consequent increased gastric acid production due to stimulation of the vagus nerve.[symptoma.com]
  • Pathophysiology Peptic ulcers occur mainly in the gastroduodenal mucosa because this tissue cannot withstand the digestive action of gastric acid (HCl) and pepsin.[slideshare.net]
  • PATHOPHYSIOLOGY Peptic ulcers occur mainly in the gastroduodenal mucosa because this tissue cannot withstand the digestive action of gastric acid (HCl) and pepsin. The use of NSAIDs inhibits the secretion of mucus that protects the mucosa.[nsgmed.com]
  • Aetiology H.pylori infection (70% 95%) (gram negative bacteria) Excessive acidity (Zollinger-Ellison Syndrome) Stress Caffeinated beverages Smoking Alcohol Familial tendency Blood type 'O' NSAID Gastrin Gasro-oesophageal reflux Pathophysiology Ingestion[examnnotes.com]
  • References: [12] Pathophysiology Clinical features Gastric ulcer Duodenal ulcer Findings common to both Dyspepsia : postprandial heaviness, early satiety, and gnawing, aching or burning epigastric pain Pain relief with antacids Potential signs of internal[amboss.com]

Prevention

  • The cause of stress ulcers such as Cushing's ulcers is not known, but increased secretion of acid in the stomach is important in their development, and prevention and treatment generally is directed at neutralizing or preventing the secretion of acid.[medicinenet.com]
  • These days, the condition is efficiently prevented in critically ill patients by decreasing acid production with antacids and histamine-2 receptor blockers.[symptoma.com]
  • A Curling's ulcer NSAID-associated ulcers : Stop NSAID if possible (if not, use H2RA, PPI, or misoprostol for prevention).[gradestack.com]
  • Science ‎ Pagina 305 - Silva P (1994) Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by ‎ Pagina 465 - Bennett NT, Schultz GS (1993) Growth factors and wound healing: part II.[books.google.it]
  • It is vital to protect the patient of severe injury or in critical state to be protected from complication such as that of stress ulcer by preventing it from occurring.[symptomscausestreatment.com]

References

Article

  1. Alain BB, Wang YJ. Cushing’s ulcer in traumatic brain injury. Chin J Traumatol. 2008;11:114–119.
  2. Silen W, Merhav A, Simson JNL. The pathophysiology of stress ulcer disease. World J Surg 1981;5:165–174.
  3. Kemp WJ, Bashir A, Dababneh H, Cohen-Gadol AA. Cushing's ulcer: Further reflections. Asian J Neurosurg. 2015 Apr-Jun;10(2):87-94.
  4. Wijdicks EF. Cushing's ulcer: the eponym and his own. Neurosurgery. 2011 Jun; 68(6):1695-1698.
  5. Cushing H. Peptic ulcer and the interbrain. Surg Gynec Obst. 1932;55:1-34
.
  6. Walsh TJ, Raine T, Chamberlin WH, Rice CL. Occult duodenal perforation complicating cerebral infarction: new problems in diagnosis of Cushing's ulcer. Am J Gastroenterol. 1982 Sep;77(9):608-610.
  7. Kamada T, Fusamoto H, Kawano S, et al. Gastrointestinal bleeding following head injury: a clinical study of 433 cases. J Trauma. 1977;17(1):44-47.
  8. Stollman N, Metz. DC Pathophysiology and prophylaxis of stress ulcer in intensive care unit patients. J Crit Care. 2004;20:35–45.
  9. Sivakumar W, Spader HS, Scaife E, Bollo RJ. A case of Cushing ulcer in an 8-month-old patient with medulloblastoma. Transl Pediatr. 2016 Apr;5(2):85-89.

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Last updated: 2019-07-11 22:13