Notes by dr. Claudio Italiano
Does your boss stress you? Has the wife left home with a black friend to dance the tango? You are without an euro in your pocket and the director of the bank calls you to pay the mortgage payments and move your "little thing" and maybe you have already cut off the light and tell your friends that you are by candlelight because you are romantic? In the meantime there has been a headache and continue to take aspirin (!), In this way you have noticed that the strong pain that takes you to the "mouth of the soul", in the middle of the chest, in the epigastric region, has worsened and is accentuated more if you take coffee, if you smoke and even if you have thought about eating something, for ex. a breadstick, to soak stomach acid.
You are probably suffering from a stress ulcer. There are two things: either follow my advice or take drastic measures, like changing jobs, changing your wife and sending your boss to that particular country. Now joking aside, a stress ulcer is a sensitive issue, which requires serious care and investigation of the case, not least a gastroscopy. This morning, finally, you had stomach ache, nausea and pitch dark stools. What are we talking about?
We speak indistinctly of "stress ulcer", "stress-related mucosal disease", "acute stress gastritis". Stress injuries can affect the stomach and the esophagus and manifest themselves as multiple point erosions or superficial ulcerations within a few hours of a stressful fact that can be given by:
-critical illness
-trauma
-surgery
-patients undergoing intensive care in the context of resuscitation (70-80% of cases)
-burns
-sepsis
-cranial lesions with intracranial hypertension
-systemic organ failure (MOF)
-extensive lesions, liver dysfunction
-pneumonia ab ingestis
EGDS, acute stress gastritis
Endoscopically there are superficial ulcers and erosions generally spread in the antrum or small gastric curve, which do not necessarily have to bleed or which cause little blood dripping, with little surrounding inflammatory reaction, such as petechial hemorrhages, or they can sometimes lead to dramatic pictures of imposing bleeding (see intestinal haemorrhages); therefore, it is not rare to have important hematemesis or blood-borne aspiration or significant bleeding from the high intestinal tract, with a sudden drop in the hemoglobin rate of 2 g / dl (see anemia) and the need to transfuse even 2 units of blood over 24 hours.
SRES is responsible for death in 30-80% of critically ill patients, if there is obviously a massive hemorrhage.
In order to have an SRES it is necessary to develop lesions of the gastric and esophageal mucosa following spikes of acid and pepsin, which are two key factors for the reading of the erosive syndrome. It is clear that the events that constitute a stress for the organism, a condition in which the body is affected by morbid events, has an increase in gastrin-mediated acid secretion, with imbalance between the so-called harmful and protective mucosal factors . In fact the mucosa is kept intact from the microcirculation that guarantees an adequate supply of nutrients, the production of mucus, the ability to neutralize the dangerous hydrogen ions, so that the mucosa ischemia is the basis of the damage and, therefore, a hypovolemic shock is responsible for the release of pro-inflammatory cytokines and increased catecholamine production. The reduction of the mucosal blood flow, in turn, causes endocellular acidosis and release of NO (nitric oxide) and oxidizing radicals, with increased cell permeability, reduction of mucosal buffer capacity and production of prostaglandins that perform protective action. which are even used in therapy. When these factors cause the hydrogen ion to penetrate into acid diffusion, then the epithelial cellular barrier breaks down and erosions and bleeding appear.
Resuscitators who fear for complications of the patient in resuscitation, especially if suffering from nosocomial pneumonia, are well aware of this. When some bio-temporal parameters such as platelets fall below 50,000 / mm3 and if the index INR (index normalized ratio, ie coagulation index) falls dangerously below 1.5, then there is a serious risk of hemorrhage, especially if the patient is in assisted ventilation for more than 48 hours.
The patient can be more or less symptomatic in the sense that the bleeding can also be misunderstood and occult, more difficultly evident. so it can be manifested with hematemesis and melena (see gastrointestinal haemorrhages), ie emission of dark stools, from the (Greek melanos aima') from the naso-gastric suction tube or, more simply, with the emission of dark stools.
The therapy and investigations are always done by your doctor.
In general guidelines recommend to keep the patient fasting in total parenteral nutrition in the most severe conditions, when, for example. blood vomit or important melena also appears. Prophylactic inhibitors of proton pump or H2 receptor antagonists should be used for intravenous administration in the critically ill patient (omeprazole and ranitidine), to prevent the pH from falling below 3.5 and activating pepsinogen in pepsin. Furthermore, platelet aggregation takes place only in a weakly acidic environment, ie up to pH 5.9, so that at particularly acidic values the platelets do not block the bleeding. Antacids reduce the frequency of bleeding by 15-20%, if acid titration is maintained at pH> 4. Mucosal agents such as sucralfate (the old antepsin and / or sucramal) are protectors of the mucosa and can play a role in protection mucosa, also administered with the tube. Let us remember, however, that they color the stools of dark and, therefore, do not alarm us always thinking of melena; it can only be a cure with iron, for example or you are taking good antepsin, as an antacid.
In the case of more trivial clinical conditions, e.g. a classic heartburn, your doctor will usually prescribe proton pump inhibitors by mouth (lansoprazole, omeprazole), also ranitidine; if the patient does not swallow, there are oral formulations that dissolve in the mouth. These drugs are taken in the morning. To these drugs, which must be protracted for at least 15 days, must also be added antacids per os, to be taken away from meals; there are so many, just go to the doctor or directly to your pharmacist. In case of lack of better, it can fit the old lemon and bicarbonate, without exaggeration with milk and antacids. (pay attention to the milk alkali syndrome!). In the meantime do not take aspirin by mouth, other painkillers, avoid smoking, coffee, chocolate, mint, sweets and, above all, meat broth that is deadly for acid production.
index gastroenterology