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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].

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]
  • Tujuan :  Tercegah terjadinya komplikasi Intervensi :  Observasi dan melaporkan tanda-tanda hematemesis, melena, pucat, TD menurun, sakit perut akut dan kekakuan.  Bantu klien dan keluarga mengambil keputusan untuk tidak merokok dan menghindari pekerjaan[khaidirmuhaj.blogspot.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]
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]
  • Tujuan :  Tercegah terjadinya komplikasi Intervensi :  Observasi dan melaporkan tanda-tanda hematemesis, melena, pucat, TD menurun, sakit perut akut dan kekakuan.  Bantu klien dan keluarga mengambil keputusan untuk tidak merokok dan menghindari pekerjaan[khaidirmuhaj.blogspot.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]
Abdominal Pain
  • Causes of Acute Abdominal Pain 210 Abdominal Pain in Pediatric Populations 211 Nonsurgical Causes of Abdominal Pain 212 Review Test 213 Hernias and Lesions of the Abdominal Wall 219 Inguinal Hernias 222 Other Hernias 228 Other Lesions of the Abdominal[books.google.com]
  • They had symptoms of bloating and abdominal sensitivity, or severe abdominal pain, or brown vomit.[symptoma.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]
  • 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]
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]
  • […] 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]

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.

Treatment

  • Treatment [ edit ] Patient should be put on Proton pump inhibitor during the course of treatment till the ICT lowers to normal level. This section is empty. You can help by adding to it .[en.wikipedia.org]
  • "Stress ulcers: their pathogenesis, diagnosis, and treatment". The Surgical Clinics of North America . 56 (6): 1469–1478. ISSN 0039-6109 . PMID 793064 . Marrone, GC; Silen, W (May 1984).[howlingpixel.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]
  • Antihelicobacter eradication treatment, complete cancellation of NSAID and steroids, treatment by high doses of proton pump inhibitors, Н2-blockers, bismuth subcitrate did not result in ulcer healing.[gastro-j.ru]
  • 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]
  • […] 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]
  • Prognosis • Kecepatan dan durasi respon sangat bergantung pada penyebabnya .[de.slideshare.net]

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]
  • Sinonim atau istitah yang ada sesuai dengan faktor etiologi, antara lain perdarahan akut tukak saluran cerna atas, tukak peptik akut, tukak Curling’s (akibat luka bakar luas), tukak Cushing (akibat Trauma SSP), gastritis akut erosiva, perdarahan gastritis[medcapes.blogspot.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]

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]
  • EPIDEMIOLOGI Ulkus peptik memiliki efek yang luar biasa pada morbiditas dan mortalitassampai dekade terakhir abad ke-20, ketika tren epidemiologi mulai menunjuk kesebuah penurunan mengesankan dalam insiden.[de.slideshare.net]
  • 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]
  • 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.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]

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]
  • […] gastritis ulcerativa sintomas neutralizer foods attack include chest pain or pressure that day I know that unexplained left arm pain is a sign of a heart attack knowing this An unusually heavy meal may increase the risk of heart gastric flu london 2016 prevent[chance4change.eu]

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: 2018-06-22 11:59