Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXX: Reoperative Abdominal Surgery

Specific Reasons for Reoperations: Stress Ulcer Hemorrhage

United States Department of Defense
Peer Review Status: Internally Peer Reviewed

Upper gastrointestinal hemorrhage in postoperative casualties is most often due to stress ulceration. The surgeon's most important priority in dealing with this problem is prevention, specifically with H2 antagonists and antacids. The mainstay and most readily available treatment uses antacids every 2 hours to titrate the gastric pH to greater than 5. Many burn and trauma units have found this condition a rarity since these aggressive preventive measures have been practiced.

Once developed, stress ulcers require vigorous evaluation and therapy. If endoscopy is available, it should be performed. Copious gastric lavage with iced saline, followed by maximum administration of H2 blockers and hourly antacids, may suffice. Transfusions are frequently necessary. Operation is usually indicated for hemodynamic instability or if more than five units of blood must be transfused. These ulcerations are frequently multiple. They may be gastric or duodenal, or both. The majority are gastric. Stress ulcers usually present in individuals with uncontrolled sepsis, in the intraperitoneal region or elsewhere. Generally, the nonoperative management of stress ulcers is not effective and lasting unless the sepsis is controlled. The choice of operative procedure for stress ulcer depends upon the experience of the surgeon. Generally, vagotomy, pyloroplasty, and oversewing of the bleeding ulcers suffice if the sepsis has been controlled. If the septic source has not been identified and addressed, then the surgeon should consider a major resectional procedure.

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Operational Medicine 2001

Health Care in Military Settings

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