A review of stress-related mucosal disease.
OBJECTIVE
To review and summarize the human and veterinary literature regarding stress-related mucosal disease (SRMD) pathogenesis, patient risk factors, and therapeutic options for prophylaxis and treatment.


BACKGROUND
SRMD is a common sequela of critical illness in human patients. Development of SRMD results from splanchnic hypoperfusion, reperfusion injury, and exposure of the gastric mucosa to acid, pepsin, and bile acids following breakdown of the gastric mucosal defense system. Human patients with the highest risk of stress ulceration include those with respiratory failure necessitating mechanical ventilation greater than 48 h or coagulopathy. Currently, little is known about the incidence and pathophysiology of SRMD in critically ill veterinary patients.


METHODS
A presumptive diagnosis can be made in high-risk patient populations following detection of occult or gross blood in nasogastric tube aspirates, hematemesis, or melena. Definitive diagnosis is achieved via esophagogastroduodenoscopy. Lesions are localized to the acid-producing portions of the stomach, the fundus, and body.


METHODS
Therapy is aimed at optimization of tissue perfusion and oxygenation. Pharmacologic interventions are instituted to increase intraluminal pH and augment natural gastric defenses. Histamine(2)-receptor antagonists, proton pump inhibitors, and sucralfate are the mainstays of therapy. In people, clinically significant bleeding may necessitate additional interventions (eg, packed red blood cell transfusions, endoscopic, or surgical hemostasis).


CONCLUSIONS
Mortality is increased in people with clinically significant bleeding compared to those patients who do not bleed. Institution of prophylaxis is recommended in high-risk patients. However, no consensus exists regarding initiation of prophylaxis, preference of frontline drug class, or indication for discontinuation of therapy. The prognosis of veterinary patients with SRMD remains unknown at this time.
Department of Emergency and Critical Care, The Animal Medical Center, New York, NY 10065, USA. andreamonnigdvm@gmail.com
Andrea A
AA
Monnig
Jennifer E
JE
Prittie
D000818:Animals; D000897:Anti-Ulcer Agents / Q000627:therapeutic use; D005753:Gastric Mucosa / Q000187:drug effects; D006471:Gastrointestinal Hemorrhage / Q000150:complications / Q000188:drug therapy / Q000662:veterinary*; D006635:Histamine H2 Antagonists / Q000627:therapeutic use; D006801:Humans; D054328:Proton Pump Inhibitors / Q000627:therapeutic use; D012307:Risk Factors; D013276:Stomach Ulcer / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy / Q000662:veterinary*; D013312:Stress, Physiological; D013392:Sucralfate / Q000627:therapeutic use
D000897:Anti-Ulcer Agents; D006635:Histamine H2 Antagonists; D054328:Proton Pump Inhibitors; D013392:Sucralfate