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Management of stress ulcers

Authors:
David W Mercer, MD
Matthew R Goede, MD
Section Editor:
David I Soybel, MD
Deputy Editor:
Wenliang Chen, MD, PhD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Mar 2017. | This topic last updated: Sep 01, 2015.

INTRODUCTION Stress ulcers were once a major cause of morbidity and mortality in
critically ill patients. However, with the advent of ulcer prophylaxis and improved critical care,
surgical intervention is only necessary for a small number of patients with life threatening
hemorrhage or perforation from stress ulcers [1].

The nonsurgical management, indications for surgery, and surgical management of patients
with stress ulcers are reviewed here. The epidemiology, pathogenesis, clinical
manifestations, and prophylaxis of stress ulcers, as well as the nonsurgical treatments of
upper gastrointestinal bleeding are discussed elsewhere. (See "Stress ulcer prophylaxis in
the intensive care unit" and "Approach to acute upper gastrointestinal bleeding in adults".)

The surgical treatment of peptic ulcer disease (not stress ulcer disease) is presented
separately. (See "Surgical management of peptic ulcer disease".)

CLASSIFICATION Stress gastritis may be referred to as diffuse mucosal injury, stress-


related mucosal disease, stress ulceration, hemorrhagic gastritis, erosive gastritis, Curlings
ulcer, and Cushings ulcer. Stress-related erosive syndrome was first described in 1971 [2]. A
commonality to all is the presence of multiple superficial erosions of the gastric mucosa,
beginning in the proximal acid-secreting portion of the stomach and progressing distally.
Cushings ulcers develop following central nervous system injury. Morphologically, Cushings
ulcers tend to be single and deep and may involve the esophagus, stomach, or duodenum
[3]. Curlings ulcers occur following burns involving greater than 30 percent total body surface
area. Curlings ulcers can occur in the stomach or duodenum [4]. Stress gastritis erosions
occur after physical trauma, shock, hemorrhage, and sepsis. Thus, stress gastritis represents
end-organ failure of the stomach in critical illness.

Stress gastritis erosions can be identified within hours following injury and occur nearly
universally (in the absence of prophylaxis) following severe shock [5]. These erosions appear
as wedge-shaped mucosal hemorrhages with necrosis of the superficial mucosal cells. If
these erosions continue to progress and extend into the submucosa, significant and life-
threatening bleeding may arise. The pathogenesis of stress gastritis is presented elsewhere.
(See "Stress ulcer prophylaxis in the intensive care unit", section on 'Pathophysiology'.)
INITIAL MANAGEMENT Despite almost universal use of ulcer prophylaxis, some critically
ill patients still develop stress ulcers, and a small number of them may develop clinically
significant bleeding. The clinical manifestations and diagnosis of stress ulcers are discussed
elsewhere. (See "Stress ulcer prophylaxis in the intensive care unit".)

When patients are diagnosed with bleeding stress ulcers, they should be promptly
resuscitated with intravenous fluid or blood products. Any coagulopathy is corrected. A
nasogastric tube should be inserted to remove gastric blood and irritants such as acid, bile,
or pancreatic secretions, which may cause further injury to the gastric mucosa. An
intravenous proton pump inhibitor should be administered, and broad-spectrum antibiotics
should be given to septic patients. Underlying sepsis is an important cause of stress ulcers.
Thus, in patients with sepsis, appropriate antibiotic coverage and source control are required
for adequate ulcer healing. (See "Evaluation and management of suspected sepsis and
septic shock in adults".)

Endoscopy is usually the first-line therapy for patients with bleeding stress ulcer disease,
both for diagnosis and treatment. Depending upon local expertise, angiographic interventions
can also stop bleeding from stress ulcers.

Resuscitation Fluid resuscitation usually begins with crystalloid infusion. Maintenance of


normothermia through utilization of fluid warmers is mandatory, as administration of large
volumes of room temperature crystalloid may cause dilutional and hypothermic
coagulopathy. Once the patient is typed and crossed, blood products including packed red
blood cells, fresh frozen plasma (FFP), and platelets should be used (in a 1:1:1 ratio) as
early as possible in place of intravenous fluid. (See "Maintenance and replacement fluid
therapy in adults".)

Correction of coagulopathy Coagulopathy is an independent risk factor for developing


clinically significant bleeding from stress gastritis [6]. Patients with overt gastrointestinal
bleeding and prolonged prothrombin time with INR greater than 1.5 or platelet count less
than 50,000 per microliter should be given FFP or platelet transfusion, respectively. Platelet
transfusions should also be given to patients with normal platelet count but who received
antiplatelet agents such as aspirin or clopidogrel [7].

Data from mixed trauma patients with massive transfusion requirements indicate that
patients with acute traumatic coagulopathy appear to benefit from receiving transfusions of
packed red blood cells, FFP or similar products (eg, PF24), and platelets in ratios
approaching 1:1:1 [8,9]. Although still controversial, these data may be applicable to patients
with life-threatening bleeding from stress gastritis.

Other hemostatic agents (recombinant human factor VIIa, prothrombin complex


concentrate, tranexamic acid, desmopressin) have been tested for use in trauma patients but
no data exist for their use in hemorrhagic stress gastritis patients. (See "Coagulopathy
associated with trauma", section on 'Pharmaceutical hemostatic agents'.)

Nasogastric tube placement Placement of a nasogastric tube is a simple yet critical


intervention in the initial treatment of hemorrhagic stress gastritis. Lavage through the
nasogastric tube can remove retained blood and clot, and suction decompresses the
stomach to prevent gastric distension (which increases gastrin production) and removes
luminal irritants [10]. Historically, gastric cooling with iced saline was also done through a
nasogastric tube as a physical means of hemostasis. (See "Nasogastric and nasoenteric
tubes".)

Antisecretory agents The administration of intravenous antisecretory agents, preferably


proton pump inhibitors, is of paramount importance. Either a proton pump inhibitor or an H2-
receptor antagonist can satisfactorily inhibit acid secretion, which promotes healing of
erosions and ulcerations. However, proton pump inhibitors have been shown to be more
efficacious than H2-receptor antagonists in the resolution of gastric bleeding [11]; although
these data come from patients with peptic ulcer disease, the findings are likely to be
applicable to patients with stress ulcers [12-15].

Endoscopy Endoscopic therapy is usually the first-line intervention for upper


gastrointestinal hemorrhage, including that from stress ulcers. Endoscopy aids in both
diagnosis and potential treatment of the bleeding source. Unfortunately, in stress ulcers
bleeding is frequently diffuse throughout the stomach without a dominant bleeding source
that would be amenable to intervention. Despite this, initial endoscopic control of bleeding is
often successful with either injection or coagulation therapy. However, the rebleed rates can
be high. (See "Overview of the treatment of bleeding peptic ulcers", section on 'Endoscopic
therapy'.)

Angiography In facilities with the requisite expertise, angiographic intervention may be


used to treat bleeding stress ulcers as well. (See "Angiographic control of nonvariceal
gastrointestinal bleeding in adults".)

When a discrete bleeding vessel is identified on angiography, it can be subsequently


embolized to stop bleeding. When no discrete bleeding source is found on angiography, an
attempt at vasopressin infusion can be made into the left gastric artery, which typically
supplies the bleeding site. Although catheter directed vasopressin infusion can successfully
halt bleeding initially, some patients rebleed after discontinuation of vasopressin. Thus, if
vasopressin infusion is initially successful in bleeding control, the left gastric artery should
then be embolized to prevent rebleed. In patients with diffuse bleeding, complete gastric
devascularization can be accomplished angiographically by embolizing both the left and right
gastric arteries and the left and right gastroepiploic arteries. Due to the extensive collateral
circulation of the stomach, in patients without a history of previous foregut surgery, the
stomach usually survives such a procedure without ischemia. (See 'Blood supply' below.)

Vasopressin has to be used with extreme caution in patients with a history of ischemic heart
disease, as it may precipitate acute coronary events. (See "Angiographic control of
nonvariceal gastrointestinal bleeding in adults".)

INDICATIONS FOR SURGERY Although most of the bleeding from stress ulcers can be
treated nonoperatively, there remains a small subset of patients who either do not respond to
nonsurgical management, rebleed after repeated nonsurgical interventions, or develop a
perforation. Alternatively, patients may be too unstable to undergo nonsurgical interventions.
For those patients, prompt surgical intervention is indicated because it provides the only
chance of survival.
Refractory bleeding Surgical intervention may be indicated in two different clinical
scenarios involving bleeding from stress ulcers.

Bleeding causing hemodynamic instability Surgical control of bleeding is a life saving


intervention in hemodynamically unstable patients with stress ulcers. These patients
frequently present with blood loss in excess of 8 units of packed red cells, and hemostasis is
unlikely to occur without surgery.

Stable patients with persistent blood loss complicating comorbid


conditions Surgical control of bleeding is sometimes warranted in patients with
persistent, refractory bleeding from stress ulcers who are showing signs of clinical
deterioration [16]. These patients are hemodynamically stable, but have ongoing transfusion
requirements. Continuation of blood product replacement therapy could lead to immunologic
and inflammatory complications, and also depletes resources.

Gastrointestinal perforation Compared with patients who have superficial ulcers from
trauma, shock, or sepsis, patients with Cushings and Curlings ulcers are more susceptible
to gastrointestinal perforations, as these two types of stress ulcers tend to be deep and
cause extensive necrosis [3,17].

Patients who develop free gastrointestinal perforation require immediate surgical


intervention. Closure of the perforation is necessary to achieve source control in order to
manage associated sepsis. Mortality without surgical intervention approaches 100 percent in
these patients. (See "Overview of gastrointestinal tract perforation", section on 'Stomach and
duodenum'.)

Because Cushings or Curlings ulcers can cause extensive necrosis of the gastric wall
before perforation occurs, more extensive gastric resection (like a subtotal gastrectomy, with
a delayed anastomosis until the patient has stabilized) may be required to treat a gastric
perforation caused by stress ulcers than a gastric perforation caused by type 1 gastric peptic
ulcers. (See 'Gastric resection procedures' below and "Surgical management of peptic ulcer
disease", section on 'Type I gastric ulcer'.)

PREOPERATIVE PREPARATION Patients who are referred for surgery because of


complicated stress ulcer disease (refractory bleeding or gastric perforation) are typically
gravely ill. Thus, thorough preoperative preparations are important to ensure the best
surgical outcomes. Many of these procedures are also performed emergently in the
operating room, often during after-hours when only limited staff is available. Thus,
cooperation among surgical, anesthesia, and nursing staff is essential to ensure a smooth
operation.

The following preparations should be made prior to the operation:

Establish two large bore (14 or 16 gauge) peripheral intravenous lines for volume
infusion. In addition, insert an arterial line and either a central venous or pulmonary
arterial catheter for hemodynamic monitoring and vasopressor administration.
Heat the operating room to an appropriate temperature (usually 85 degrees
Fahrenheit); cold operating room air temperatures can exacerbate hypothermia and
therefore coagulopathy.
Ensure that blood products (typed and cross-matched packed red blood cells, fresh
frozen plasma, and platelets) are readily available.
Have adequate numbers of fluid warmers and rapid infusers readily available.
Use pneumatic compression devices for prophylaxis against venous
thromboembolism. (See "Prevention of venous thromboembolic disease in surgical
patients".)
Give antibiotic prophylaxis prior to incision in patients who are not already receiving
antibiotics. (See "Antimicrobial prophylaxis for prevention of surgical site infection in
adults".)

SURGICAL ANATOMY The stomach resides in the left upper quadrant of the abdomen.
Anteriorly, it is contained by the chest and abdominal walls, and usually a large portion is
covered by the left lateral segment of the liver. Superiorly and posteriorly, it is confined by the
diaphragm. The spleen occupies its position superiorly and laterally to the greater curvature.
The pancreas resides in the lesser sac, posterior to the stomach. Inferiorly, the stomach is
bordered by the transverse colon. The stomach is fixed at the gastroesophageal junction and
the pylorus (figure 1). However, between these two points the stomach is mobile, which
assists in its ability to distend.

The most proximal portion of the stomach that attaches to the intraabdominal esophagus is
the cardia. Between the esophagus and the cardia is the lower esophageal sphincter. The
highly distensible fundus is distal to the cardia and is bordered by the angle of His, which
forms between the left edge of the esophagus and the fundus, the diaphragm superiorly, and
the spleen laterally. Continuing distally is the body of the stomach. This is the largest portion
of the stomach and contains the majority of the parietal cells. The body is defined from the
antrum by the angularis incisura, at which point the lesser curvature of the stomach acutely
angles towards the right. The pylorus then lies between the antrum of the stomach and the
first portion of the duodenum.

Blood supply Most of the blood supply to the stomach arises from the celiac artery
(figure 2). Four vessels supply the majority of the stomach. The left and right gastric arteries
supply the lesser curvature. The left and right gastroepiploic arteries supply the greater
curvature. The largest artery to the stomach is the left gastric artery. In 15 to 20 percent of
patients, an aberrant left hepatic artery originates from the left gastric artery. This is of
special surgical significance because if the left gastric artery is ligated or embolized
proximally to the take off of an aberrant left hepatic artery, it may lead to ischemia of the left
lobe of the liver.

The stomach also has a rich collateral circulation. A substantial amount of the circulation to
the proximal stomach can be provided by the inferior phrenic arteries. The short gastric
arteries arising from the splenic circulation can supply much of the greater curvature. This
rich collateral circulation is what allows the stomach to survive if gastric devascularization is
attempted to control catastrophic bleeding.
The venous drainage from the lesser curvature is through the left gastric vein (also known as
the coronary vein) and the right gastric vein, which both drain into the portal vein. The left
gastroepiploic vein drains into the splenic vein and the right gastroepiploic vein drains into
the superior mesenteric vein.

Vagal innervation The sympathetic innervation of the stomach is from the celiac plexus.
The parasympathetic innervation of the stomach is from the vagus nerve (figure 3). The
vagus nerve arises in the vagal nucleus in the brain, travels through the carotid sheath in the
neck, and then enters the mediastinum where it divides into numerous branches around the
esophagus. At the level of the diaphragmatic hiatus, those vagal branches then coalesce into
the left (anterior) and right (posterior) vagus nerves. The left vagus nerve branches to give off
the hepatic branch and the anterior nerve of Latarjet, which courses down the lesser
curvature of the stomach. The first branch off of the right vagus nerve is the criminal nerve of
Grassi. The criminal nerve of Grassi is of particular interest because if it is not divided,
recurrent ulcers can develop. The right vagus nerve continues to travel down the lesser
curvature of the stomach, giving off branches to the celiac plexus along the way.

In order to perform a truncal vagotomy, both left and right vagus nerves are divided above
the hepatic and celiac branches. A selective vagotomy divides below these branches, which
preserves the hepatic and pyloric branches.

SURGICAL APPROACH Surgery for stress ulcer disease can be challenging because
patients are often ill from both their underlying disease processes (eg, sepsis), as well as
acute hemorrhagic shock. For bleeding patients who are acidotic, hypothermic, or
coagulopathic, a staged surgical approach appears safer [18].

The initial stage of the operation is usually done with the primary goal of bleeding control
[19,20]. Once that is achieved, the second stage of the operation needs to be tailored to
each individual patient based on their hemodynamic stability. Stable patients go on to have a
vagotomy and pyloroplasty before abdominal closure, while unstable patients are sent back
to the intensive care unit for further resuscitation with an open abdomen. More elaborate
procedures such as gastrectomy or gastric devascularization are now rarely used because of
the high morbidity and mortality associated with them.

Abdominal incision and exploration A long midline incision is recommended for its
versatility and expediency. The entire abdomen is then quickly but systematically explored to
exclude any pathology including bleeding, perforation, infection, obstruction, or tumor. The
focus of the surgeon is then directed towards the stomach.

Anterior gastrotomy and oversewing of bleeders The simplest and most


straightforward operation is a long anterior gastrotomy with oversewing of all potential
bleeding sources. As discussed earlier, due to the diffuse nature of stress gastritis, there is
rarely a singular source of bleeding in those patients.

In stress gastritis, the bleeding sources often reside high along the lesser curvature close to
the esophagogastric junction [21]. Therefore, the initial gastrotomy needs to be made high
enough to allow for eversion and close inspection of the flattened rugal folds of the upper
stomach [22] (figure 4). A counter incision in the form of a longitudinal gastroduodenostomy
can be made across the pylorus after a Kocher maneuver to mobilize the duodenum. This
would allow for inspection of the distal stomach, pyloric channel, and proximal duodenum.

Subsequent approach based upon hemodynamic stability

Stable patients In patients who are hemodynamically stable after incision, exploration,
and oversewing of bleeders, a vagotomy and pyloroplasty can be added, followed by closure
of the abdomen.

Vagotomy and drainage procedure Some forms of vagotomy, usually in combination


with a drainage procedure, have a long-standing history in the treatment of peptic ulcer
disease (see "Vagotomy"). Not surprisingly, vagotomy has been used in conjunction with
other procedures in the treatment of stress gastritis. Vagotomy reduces luminal acid
production and has some efficacy in the treatment of stress gastritis in those patients
requiring surgery [23,24]. Vagotomy and pyloroplasty (or other drainage procedure) can be
performed in this setting, although ligation of actively bleeding ulcers must be accomplished
first.

Closure The anterior gastrotomy is closed in two layers. If a gastroduodenostomy is


made separately, its closure can be incorporated into a standard Heineke-Mikulicz
pyloroplasty.

Unstable patients In patients who are hemodynamically unstable after incision,


exploration, oversewing of bleeders, and closure of the gastrotomy, the abdomen should be
left open using a negative pressure dressing or some other temporary closure method to
prevent abdominal compartment syndrome and expedite a second look procedure. Leaving
the abdomen open also decreases operative time and allows the patient to return to intensive
care unit for further resuscitative efforts as soon as possible.

Patients may be returned to the operating room when hemodynamically stable for vagotomy
and pyloroplasty (or other drainage procedure), followed by abdominal closure (usually within
24 to 48 hours) [18].

Rarely performed procedures Gastric resectional procedures and total gastric


devascularization had been used to treat patients with bleeding stress ulcers. However,
these procedures are rarely used because of their high morbidity and mortality.

Gastric resection procedures Most authors advocate for reserving resectional


procedures for reoperations if a patient develops rebleeding after the initial operation [25-28].
Before proton pump inhibitors were widely used, gastric resection was sometimes carried out
as the index operation because of rebleeding rates achieved with simple vagotomy and
pyloroplasty [29,30].

Partial gastrectomy A partial gastrectomy can be performed if the bleeding is confined to


a portion of the stomach (for example, the antrum). However, this is rarely the case with
stress ulcers, which tend to be multifocal. In addition, antrectomy is of limited benefit
because stress ulcers usually start in the fundus [31].
Alternatively, a sleeve gastrectomy could be performed in combination with vagotomy and
pyloroplasty in patients whose bleeding is confined to the body of the stomach. This would
control bleeding by eliminating a majority of the fundus and body, and have the added benefit
of the acid suppression from vagotomy.

Specific techniques of partial gastrectomy are also discussed elsewhere. (See "Partial
gastrectomy and gastrointestinal reconstruction".)

Subtotal or total gastrectomy Subtotal and total gastrectomy are rarely performed now
that proton pump inhibitors are in widespread use. However, in the past, a subtotal
gastrectomy or even total gastrectomy was performed in dire circumstances to control
bleeding. Unfortunately, patients requiring a subtotal gastrectomy had a mortality
approaching 80 to 100 percent [29,32]. If performed, most surgeons would advocate for a
delayed anastomosis after the gastrectomy, allowing the patient to be resuscitated out of
shock before performing a definitive anastomosis 24 to 48 hours later, analogous to damage
control laparotomies in trauma patients.

During gastrectomy, leaving a cuff of proximal stomach on the esophagus may be desirable,
because an esophageal-jejunal anastomosis is associated with a higher leak rate than a
gastro-jejunal anastomosis. Before using any mechanical stapling device, the surgeon must
remember to call for removal of the nasogastric tube to avoid the disastrous complication of
entangling the tube by the staple line. A more detailed discussion on total gastrectomy and
reconstruction is contained elsewhere. (See "Total gastrectomy and gastrointestinal
reconstruction".)

Gastric devascularization In lieu of resectional procedures, complete gastric


devascularization can be performed for long-lasting hemostasis. After oversewing any visible
bleeding through a gastrotomy, the left and right gastric arteries, and the left and right
gastroepiploic arteries are ligated. Although the stomach may initially appear ischemic
following ligation, it frequently does not progress to full-thickness necrosis given its rich
collateral circulation [33]. (See 'Blood supply' above.)

POSTOPERATIVE CARE Survival of patients with severe stress ulcers is largely


dependent upon the ability to reverse the patient's underlying condition. However, if the
patient survives the initial operation with successful control of bleeding, valuable time is
gained for further resuscitation and correction of any organ dysfunction.

Following operative intervention, the patient is returned to the intensive care unit to continue
resuscitation and medical management:

Treatment with intravenous proton pump inhibitors is continued if any part of the
stomach remains.
Antibiotics and antifungal medications are continued.
Normothermia needs to be maintained.
Coagulopathy needs to be controlled.
As noted above, the initially unstable patient may be returned to the operating room in
24 to 48 hours if hemodynamically stable for definitive procedure, anatomical
restoration, and abdominal closure. (See 'Unstable patients' above.)
Enteral feeding can commence when the patient is weaned down on vasopressors,
provided that a feeding tube is placed distal to an anastomosis.
A water soluble contrast upper gastrointestinal series should be performed to rule out
a leak in those patients undergoing gastrectomy prior to starting oral intake.

FOLLOW-UP CARE Patients who have bleeding control by simple oversewing of the
ulcerations, endoscopic therapy, or angiographic intervention only will likely require proton
pump inhibitors for several months. During this period, the gastric mucosa remains friable,
and may take a significant amount of time to heal completely. However, those patients who
also underwent vagotomy do not require antisecretory therapy because vagotomy
substantially reduces gastric acid secretion.

Long-term continuation of the proton pump inhibitor after ulcer healing is complete is
controversial. Once acute shock has resolved and patients recover from their underlying
illness, the nidus for stress ulceration has been removed as has the need for long-term
antisecretory therapy.

Patients who have had gastric resection and reconstruction can develop complications
including osteoporosis, iron deficiency anemia, pernicious anemia, and malnutrition. These
issues are discussed elsewhere in detail. (See "Bariatric surgery: Postoperative nutritional
management".)

MORBIDITY AND MORTALITY Surgical intervention acts as a temporizing measure to


halt bleeding, the most acute threat to life, and thereby allows more time to reverse the shock
state. Efficacy of such intervention is therefore directly linked to the successful resolution of
the underlying shock condition and control of any associated sepsis. Without resolution of the
underlying disease process, any surgical intervention is destined to fail.

Thus, it is not surprising that patients who develop overt bleeding from stress ulcers continue
to have a poor prognosis, with mortality rates ranging from 30 to 70 percent. Those who
require surgical intervention have mortality rates in excess of 50 percent [29]. Rebleeding
rates following surgical interventions vary depending on the series examined, ranging from
20 to 40 percent [29].

Surgical intervention also carries the additional risks of anastomotic leak, surgical site
infections, and abdominal wall hernia.

SUMMARY AND RECOMMENDATIONS

Superficial stress ulcers can occur after physical trauma, shock, hemorrhage, and
sepsis. They can cause major morbidity and mortality in critically ill patients because of
the risk of bleeding. In addition, patients with two other forms of stress ulcers, Cushings
ulcer (following head trauma or brain surgery) and Curlings ulcer (following significant
burn), are also susceptible to gastrointestinal perforations. (See 'Introduction' above.)
For patients diagnosed with bleeding stress ulcers, resuscitative efforts start with
intravenous proton pump inhibitors, volume repletion, and correction of coagulopathy.
Antibiotics are given to patients with underlying sepsis. A nasogastric tube is inserted for
gastric lavage and decompression. Endoscopy or angiography can be used as first-line
therapy to localize the bleeding sources and stop them if possible. (See 'Initial
management' above.)
Surgical consultation is indicated for severe bleeding causing hemodynamic instability,
free gastrointestinal perforation, or refractory bleeding compromising comorbid medical
conditions. (See 'Indications for surgery' above.)
For patients with a bleeding stress ulcer, the goal of the surgery is to control bleeding.
We typically make a long gastrotomy high on the anterior wall of the stomach in order to
identify and oversew all bleeders. A truncal vagotomy with pyloroplasty could be added
if the patients condition permits. Gastric resection and devascularization procedures are
rarely performed and are usually reserved for reoperations for stress ulcer bleeding, or
for patients who present with a gastric perforation. (See 'Surgical approach' above.)
After bleeding control, the abdomen can be left open to expedite the surgery and to
prevent abdominal compartment syndrome in unstable patients. These patients are
promptly returned to the intensive care unit for further resuscitative efforts before being
brought back in 24 to 48 hours for second look, anatomical restoration, and abdominal
closure. (See 'Postoperative care' above.)
Following surgical intervention, patients frequently require continued proton pump
inhibitors for acid suppression and/or nutritional supplements dictated by the specific
procedure they undergo. (See 'Follow-up care' above.)
Patients who develop overt bleeding or perforation from stress ulcers continue to have
a poor prognosis, with mortality rates ranging from 30 to 70 percent. Those who require
surgical intervention have mortality rates in excess of 50 percent. Much of the morbidity
and mortality are attributed to the patients underlying disease processes.
(See 'Morbidity and mortality' above.)
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