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.
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  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 . 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 .
The three patients described in the original 1932 paper of Cushing   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.  for aphasic patients. The lesions have about a 17% risk of bleeding  .
Acute stress gastritis following brain injury has been on the decline since the introduction of prophylaxis using antacids and histamine-2 receptor antagonists  . Nevertheless, the condition still occurs for various reasons, one of which is a large number of head injuries due to traffic accidents . 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 .
Entire Body System
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]
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]
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]
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]
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]
[…] 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]
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]
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]
Jaw & Teeth
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]
Perforation of a Cushing ulcer should be anticipated in patients with brain injuries .
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 . Angiography is used in patients who have massive bleeds. Various laboratory parameters are performed, for example, serum gastrin levels.
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]
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- Kemp WJ, Bashir A, Dababneh H, Cohen-Gadol AA. Cushing's ulcer: Further reflections. Asian J Neurosurg. 2015 Apr-Jun;10(2):87-94.
- Wijdicks EF. Cushing's ulcer: the eponym and his own. Neurosurgery. 2011 Jun; 68(6):1695-1698.
- Cushing H. Peptic ulcer and the interbrain. Surg Gynec Obst. 1932;55:1-34 .
- 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.
- 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.
- Stollman N, Metz. DC Pathophysiology and prophylaxis of stress ulcer in intensive care unit patients. J Crit Care. 2004;20:35–45.
- 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.