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Chapter 22. Gastroenterology and Liver Diseases

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A 71-year-old man presented to the emergency department (ED) for productive cough, dyspnea, and subjective fevers. He has mild intermittent asthma for which he takes albuterol as needed. Vital signs showed a fever of 101°F, respiratory rate of 38 breaths/min, heart rate of 112 bpm, and blood pressure of 86/45 mm Hg. Chest x-ray showed right lower lobe infiltrates. A diagnosis of septic shock secondary to severe pneumonia was made, and the patient was subsequently intubated and admitted to the intensive care unit (ICU). His hemodynamic status had initially improved, but on the third day of admission, while still in the ICU, the patient started passing melena and his hemoglobin (Hgb) dropped to 8 mg/dL from 11 mg/dL at the time of admission. His blood urea nitrogen (BUN) was 36 mg/dL, with a serum creatinine of 0.7 mg/dL. Esophagogastroduodenoscopy (EGD) was done and showed multiple superficial gastric ulcers (shown below). What is the likely underlying etiology for the ulcers?

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Multiple gastric ulcers (arrows) at different stages of healing.

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A. Nonsteroidal anti-inflammatory drugs (NSAIDs)

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B. Helicobacter pylori gastritis

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C. Stress ulcer

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D. Malignancy

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E. Cytomegalovirus

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C. The likely etiology for this patient’s ulcers is critical illness–related stress. Stress ulcers, also called stress-related mucosal injury, are seen in critically ill patients and are thought to result from mucosal ischemia and diminished mucosal protection. The most common location of such ulcers is the stomach, but they can also occur in other sites of the gastrointestinal (GI) tract (eg, duodenum and rectum). Bleeding stress ulcers are estimated to occur in 1.5% of critically ill patients. The risk factors are mechanical ventilation, coagulopathy, prior upper GI (UGI) bleeding, sepsis, prolonged ICU admission, and high-dose steroids. A large multicenter study has shown that oral omeprazole and intravenous (IV) cimetidine are equally effective in preventing bleeding in these patients. In this patient, however, since ulcers already were present, proton pump inhibitor (PPI)-based therapy is preferred over histamine receptor blocker.

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The patient is not on NSAIDs (choice A) and is not known to have an immunosuppressive illness that would predispose to cytomegalovirus (choice E). In view of the high prevalence of H pylori in the community, this patient could have H pylori gastritis (choice B), but the temporal presentation of his ulcer bleeding during his ICU stay is most consistent with ongoing critical illness being the trigger. The acute presentation argues against malignancy as a cause for this patient’s presentation (choice D).

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A 67-year-old man presented to the ED after 1 episode of syncope and 24 hours of passing ...

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