Stress Ulcer

Pada Luka Bakar

Andi Muhammad Ardan
Pembimbing
Dr. Agus Santoso Budi, SpBP-RE(K)

LATAR
BELAKANG

Definisi
Stress-induce gastritis, stress-related erosive

syndrome, stres ulcer syndrome, stress-related

mucosal disease
Stress ulcer adalah suatu syndrome yang

ditandai dengan adanya perdarahan akut atau

perforasi saluran cerna bagian atas akibat
kerusakan mukosa pada pasien yang menderita
penyakit atau trauma yang berat, pada luka bakar
luas disebut Curling ulcer.
Basil A. Pruitt, Jr., M.D., and Cleon W. Goodwin, Jr., M.D, Stress Ulcer Disease in the Burned
3 Patient , World J. Surg. 5,209-222, 1981

Epidemiology
Di amerika serikat, 90-100% pasien mengalami

stress ulcer dalam 24 jam setelah oncet stressor

Awal tahun 1970 Curlings ulcer didapatkan pada
23% pasien yang menderita luka bakar
Insiden Curlings ulcer meningkat seiring
meningkatnya luas luka bakar

1.
2.
3.
4

ASHP Therapeutic Gidelines on Stress Ulcer Prophylaxis, AJHP 1999;56(4) 347-379

Basil A. Pruitt, Jr., M.D., and Cleon W. Goodwin, Jr., M.D, Stress Ulcer Disease in the
Burned Patient , World J. Surg. 5,209-222, 1981
Johan C Clarke, MD; Chief Editor: Julian Katz, MD, Stress-Induced Gastritis , Medscape
Reference, July 2012

Pathophysiology

Prevention and management of stress ulcers in the ICU, Gavin Joynt September 2003
5

Pathophysiology of Curlings
Ulcers
I. Initial injury:
Mucosal Ischemia
II. Factors causing progression:
1. Intraluminal acid
2. Increased acid back-diffusion
3. Duodenal reflux of bile salts and lysolecithin
4. Sepsis
5. Nasogastric tube trauma
6. Decrease in sulfated muco-substances
7. Impaired energy supply, e.g., starvation or inadequate nutrition
III. Protective factors
1. Mucous production
2. Mucosal proliferation
3. Maintenance of muco
Basil A. Pruitt, Jr., M.D., and Cleon W. Goodwin, Jr., M.D, Stress Ulcer Disease in the Burned
6 Patient , World J. Surg. 5,209-222, 1981

Morbidity/Mortality
Cook dkk melakukan penelitian dengan

jumlah sampel yang luas (n=2252)

pasien dengan perdarahan signifikan
saluran cerna bagian atas.
Tingkat mortalitas pada pasien:
48.5% with significant bleeding
9.1% without significant bleeding

Cook DJ, et al. Risk factors for gastrointestinal bleeding in critically ill patients. NEJM
1994;330(6):377-81

Gejala Klinis
Gejala tersering adalah perdarahan

gastrointestinal bagian atas (Hematemesis 2,3

kali lebih sering daripada melena pada 96%
pasien dengan Curlings ulcer )
Syok terjadi pada 43% pasien dengan Curling
ulcer
Distensi abdomen dapat terjadi pada 9% pasien
Abdominal pain dapat terjadi dan biasanya timbul
bila telah terjadi perforasi atau terjadi perdarahan
yang hebat
Pada 15% pasien dengan Curlings Ulcer, dapat
Basil A. Pruitt, Jr., M.D., and Cleon W. Goodwin, Jr., M.D, Stress Ulcer Disease in the Burned
Patient , timbul
World J. Surg.
5,209-222, 1981 ulkus gaster maupun
gejala-gejala

Pemeriksaan Laboratorium
Kewaspadaan terhadap gejala klinis merupakan
kunci awal penegakan diagnosis.
2. Pemeriksaan laboratorium sederhana yang
dapat membantu:
1.

Hematocrit

Coagulation profile

Johan C Clarke, MD; Chief Editor: Julian Katz, MD, Stress-Induced Gastritis , Medscape
Reference, July 2012

MEDICAL CARE

10

Terapi dan Managemen

Tujuan utama dari terapi dan managemen
adalah

Prophylaxis
Basil A. Pruitt, Jr., M.D., and Cleon W. Goodwin, Jr., M.D, Stress Ulcer Disease in the Burned
11 Patient , World J. Surg. 5,209-222, 1981

Key Guideline Points The Big 3

1.

Coagulopathy
platelet count of <50,000mm3
INR>1.5
PTT of >2 times the control

2.

Mechanical Ventilation

3.

Longer than 24 hours

Recent GI ulcers/bleeding

Within 12 months of admission

ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis, AJHP 1999;56(4) 347-379

12

Key Guideline Points The Little

2 or more of the following:

Sepsis
2. ICU>1 week
3. Occult Bleeding within 6 days
4. High dose corticosteroids
1.

250mg Hydrocortisone
50mg Methylprednisone

These factors are not consistently found to be

contributing factors, but they are significant in
some studies

13 ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis, AJHP 1999;56(4) 347-379

Why Sepsis
One of the early identified causes of stress ulcers

was sepsis (n=30)

Significant for
Incidence
Severity

Ulcers rapidly resolved after sepsis resolved

14

Le Gall JR, et al. Acute gastroduodenal lesions related to severe sepsis. Surgery, Gynecology &
Obstetrics. 142(3):377-80, 1976 Mar

Why 7 Day Stay

Study of patients in the ICU on mechanical

ventilation (n=179)
Patients with significant GI Bleeding (14%) had
Longer stays (14 vs. 4 days)
Longer ventilation time (9 vs. 4 days)
Only 3% of patients with stays less than 5 days had

GI Bleeing events

Schuster DP. Rowley H. Feinstein S. McGue MK. Zuckerman GR . Prospective evaluation of the risk of
upper gastrointestinal bleeding after admission to a medical intensive care unit. American Journal of
Medicine. 76(4):623-30, 1984 Apr.
15

Agen dan Dosis

Sucralfate

Histamine 2 (H2) receptor blockers

proton pump inhibitors (PPIs)

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Johan C Clarke, MD; Chief Editor: Julian Katz, MD, Stress-Induced Gastritis , Medscape
Reference, July 2012

Efek samping Acid Suppression

Therapy
Hospital Acquired Pneumonia(HAP)1
C Difficile2
Osteoporosis & Hip Fractures3,4

1.
2.
3.
174.

Herzig HJ et al, JAMA 2009;301(20):2120-2128

Dial, S, Delaney, AC, Barkun AN, et al. JAMA 2005;294(3):2989-2995
Yang et al. JAMA 2006:296(24):2947-2953
Targownik, LE et al. CMAJ 2008:179(4):319-326

Applications for Pharmacy

Document the indication for ongoing therapy
Big 3
Little 4

Discontinue therapy if not indicated

Reduce the risk to patients
Reduce costs

Discuss the indications with the patient/provider

Appropriate indications and duration of therapy

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Kesimpulan
Stress ulcer adalah suatu syndrome yang ditandai dengan

adanya perdarahan akut saluran cerna bagian atas akibat

kerusakan mukosa pada pasien yang menderita penyakit
atau trauma yang berat, pada luka bakar luas disebut
Curling ulcer.
Insiden Curlings ulcer meningkat seiring meningkatnya

luas luka bakar

Terapi utama pada Curlings ulcer adalah prophylaksis atau

pencegahan
Berikan terapi prophylaksis jika ada indikasi
Hentikan bila sudah tidak ada indikasi
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Document, Discontinue, Discuss

Terima Kasih

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