Edit concept Question Editor Create issue ticket

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].

Inguinal Hernia
  • Hernias 222 Other Hernias 228 Other Lesions of the Abdominal Wall 230 Review Test 233 The Esophagus 237 Tests of Esophageal Anatomy and Function 240 Disorders of Esophageal Motility 242 Gastroesophageal Reflux Disease GERD and Esophageal Hernia 245[books.google.ro]
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.ro]
  • 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]
  • pain – angina; AAA; musculoskeletal; pancreatitis Initial management of peptic ulcer disease and H. pylori infection Lifestyle advice Weight loss; smoking cessation; avoid precipitants; raise the head of the bed; don’t eat late at night Stop NSAIDs [oxfordmedicaleducation.com]
Melena
  • Constipation Diarrhea Infectious Intestinal adhesions Rectum Proctitis Radiation proctitis Proctalgia fugax Rectal prolapse Anismus Anal canal Anal fissure / Anal fistula Anal abscess Hemorrhoid Anal dysplasia Pruritus ani GI bleeding / BIS Upper Hematemesis Melena[en.wikipedia.org]
  • 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]
  • […] duodenal ulcer; hematemesis more common than melena 24.[slideshare.net]
Hematemesis
  • […] impaction Constipation Diarrhea Infectious Intestinal adhesions Rectum Proctitis Radiation proctitis Proctalgia fugax Rectal prolapse Anismus Anal canal Anal fissure / Anal fistula Anal abscess Hemorrhoid Anal dysplasia Pruritus ani GI bleeding / BIS Upper Hematemesis[en.wikipedia.org]
  • […] 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
  • […] reflux (LPR) Esophageal stricture Megaesophagus Stomach Gastritis Atrophic Ménétrier's disease Gastroenteritis Peptic (gastric) ulcer Cushing ulcer Dieulafoy's lesion Dyspepsia Pyloric stenosis Achlorhydria Gastroparesis Gastroptosis Portal hypertensive gastropathy[en.wikipedia.org]
  • 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]
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]

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.

Esophageal Motility Disorder
  • motility disorder Nutcracker esophagus Achalasia Diffuse esophageal spasm Gastroesophageal reflux disease (GERD) Laryngopharyngeal reflux (LPR) Esophageal stricture Megaesophagus Stomach Gastritis Atrophic Ménétrier's disease Gastroenteritis Peptic ([en.wikipedia.org]

Treatment

  • "Pathogenesis, diagnosis and treatment of acute gastric mucosal lesions". Clinics in Gastroenterology. 13 (2). ISSN 0300-5089.[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]
  • 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]
  • "Pathogenesis, diagnosis and treatment of acute gastric mucosal lesions" . Clinics in Gastroenterology . 13 (2). ISSN 0300-5089 .[howlingpixel.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]
  • 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]
  • Epidemiology References: [1] [2] [3] [4] [5] Epidemiological data refers to the US, unless otherwise specified.[amboss.com]
  • […] 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]
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]
  • Award-winning clinical nurse specialists Marianne Baird and Sue Bethel separate the content first by body system and then by disorder, with each disorder including a brief description of pathophysiology, assessment, diagnostic testing, collaborative management[books.google.ro]
  • 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]

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]
  • A Curling's ulcer NSAID-associated ulcers : Stop NSAID if possible (if not, use H2RA, PPI, or misoprostol for prevention).[gradestack.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]
  • 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]
  • They may suffer from either type of stress ulcer and are often given preventative medication while they are hospitalized.[wisegeek.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.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2018-06-22 11:59