Stress gastric ulcer after cardiac surgery: Pathogenesis risk factors and medical management


Stress ulcer lesions of upper gastrointestinal tract are well recognized in patients undergoing open cardiac surgery. Gastrointestinal bleeding following cardiac surgery is infrequent with significant morbidity and mortality. The pathogenesis of mucosal lesions and subsequent haemorrhage is complex and multifactorial. The diagnosis as well as the treatment of this complication remains a challenge for surgeons. Identifying the source of bleeding can be difficult. Despite of the successful control of haemorrhage using various combinations of endoscopic and pharmacological therapies, the mortality rate remains unchanged. Benefit of routine stress ulcer prophylaxis remains controversial.

Share and Cite:

Houssa, M. , Atmani, N. , Nya, F. , Abdou, A. , Moutakiallah, Y. , Bamous, M. , Drissi, M. and Boulahya, A. (2013) Stress gastric ulcer after cardiac surgery: Pathogenesis risk factors and medical management. World Journal of Cardiovascular Diseases, 3, 312-316. doi: 10.4236/wjcd.2013.33049.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Berkowitz, D. (1963) Fatal gastrointestinal hemorrhage; diagnostic implications from a study of 200 cases. The American Journal of Gastroenterology, 40, 372-377.
[2] Rey, J.F., Monnot, F., Lombart, J., Sabatier, M., et al. (1983) Appport de l’endoscopie dans le diagnostic et le traitement des hémorragies digestives survenant dans un service de chirurgie cardiaque. Acta Endoscopica, 13, 109113. doi:10.1007/BF02979791
[3] Gaer, J.A., Shaw, A.D., Wild, R., Swift, R.I., Munsch, C.M., Smith, P.L. and Taylor, K.M. (1994) Effect of cardiopulmonary bypass on gastrointestinal perfusion and function. The Annals of Thoracic Surgery, 57, 371-375. doi:10.1016/0003-4975(94)90999-7
[4] Krasna, M.J., Flancbaum, I., Trooskin, S.Z., Fitzpatrick, J.C., Scholz, P.M., Scott, G.E., Spotnitz, A.J. and Mackenzie, J.W. (1988) Gastrointestinal complications after cardiac surgery. Surgery, 104, 773-780.
[5] Moneta, G.L., Misbach, G.A. and Ivey, T.D. (1985) Hypoperfusion as a possible factor in the development of gastrointestinal complications after cardiac surgery. The American Journal of Surgery, 149, 648-650. doi:10.1016/S0002-9610(85)80148-3
[6] Welling, R.E., Rath, R., Albers, J.E. and Glasser, R.S. (1986) Gastrointestinal complications after cardiac surgery. Archives of Surgery, 121, 1178-1180.
[7] Van Der Voort, P.H. and Zandstra, D.F. (2000) Pathogenesis, risk factors, and incidence of upper gastrointestinal bleeding after cardiac surgery: Is specific prophylaxis in routine bypass procedure needed? Journal of Cardiothoracic and Vascular Anesthesia, 14, 293-299. doi:10.1016/S1053-0770(00)90128-9
[8] Egleston, C.V., Wood, A.E., Gorey, T.F. and McGovern, E.M. (1993) Gastrointestinal complications after cardiac surgery. Annals of the Royal College of Surgeons of England, 75, 52-56.
[9] Ait Houssa, M., Selkane, C., Moutaki Allah, Y., Elbekkali, Y., Amahzoune, B., Wahid, F., Abdou, A., Bamous, M., Boulahya, A., Elkirat, A., Drissi, M., Ibat, D. and Jabrani, K. (2007) Hémorragies digestives hautes après chirurgie cardiaque. Annales de Cardiologie et d’Angéiologie, 56, 126-129. doi:10.1016/j.ancard.2007.02.002
[10] Yoshida, K., Matsumoto, M., Sugita, T., Nishizawa, J., Matsuyama, K., Tokuda, Y. and Matsuo, T. (2005) Gastrointestinal complications in patients undergoing coronary artery bypass grafting. Annals of Thoracic and Cardiovascular Surgery, 11, 25-28.
[11] Aljarallah, B., Wong, W., Modry, D. and Fedorak, R. (2008) Prevalence and outcome of upper gastrointestinal bleeding post-coronary artery bypass graft. International Journal of Health Sciences, 2, 69-76.
[12] Behrens, R., Hofbeck, M., Singer, H., Scharf, J. and Rupprecht, T. (1994) Frequency of stress lesions of the upper gastrointestinal tract in paediatric patients after cardiac surgery: Effects of prophylaxis. British Heart Journal, 72, 186-189. doi:10.1136/hrt.72.2.186
[13] Perugini, R.A., Orr, R.K., Porter, D., Dumas, E.M. and Maini, B.S. (1997) Gastrointestinal complications following cardiac surgery. An analysis of 1477 cardiac surgery patients. Archives of Surgery, 132, 352-357. doi:10.1001/archsurg.1997.01430280026003
[14] McSweeney, M.E., Garwood, S., Levin, J., Marino, M.R., Wang, S.X., Kardatzke, D., Mangano, D.T. and Wolman, R.L. (2004) Adverse gastrointestinal complications after cardiopulmonary bypass: Can outcome be predicted from preoperative risk factors? Anesthesia & Analgesia, 98, 1610-1617. doi:10.1213/01.ANE.0000113556.40345.2E
[15] Alebouyeh, N., Toefigh, M., Ghasemzadeh, N., Mirheydari, S. and Azargashb, E. (2007) Predictors of gastrointestinal perforation in patients undergoing coronary artery bypass graft (CABG) surgery in Tehran, Iran. Annals of Thoracic and Cardiovascular Surgery, 13, 251-253.
[16] Ohri, S.K., Bjarnason, I., Pathi, V., Somasundaram, S., Bowles, C.T., Keogh, B.E., Khaghani, A., Menzies, I., Yacoub, M.H. and Taylor, K.M. (1993) Cardiopulmonary bypass impairs small intestinal transport and increases gut permeability. The Annals of Thoracic Surgery, 55, 10801086. doi:10.1016/0003-4975(93)90011-6
[17] Oudemansvan Straaten, H.M., Jansen, P.G., Hoek, F.J., van Deventer, S.J., Sturk, A., Stoutenbeek, C.P., Tytgat, G.N., Wildevuur, C.R. and Eysman, L. (1996) Intestinal permeability, circulating endotoxin, and postoperative systemic responses in cardiac surgery patients. Journal of Cardiothoracic and Vascular Anesthesia, 10, 187-194. doi:10.1016/S1053-0770(96)80235-7
[18] Sinclair, D.G., Haslam, P.L., Quinlan, G.J., Pepper, J.R. and Evans, T.W. (1995) The effect of cardiopulmonary bypass on intestinal and pulmonary endothelial permeability. Chest, 108, 718-724. doi:10.1378/chest.108.3.718
[19] Mela, L. (1981) Direct and indirect effects of endotoxin on mitochondrial function. Progress in Clinical and Biological Research, 62, 15-21.
[20] Baue, A.E. (1993) The role of the gut in the development of multiple organ dysfunction in cardiothoracic patients. The Annals of Thoracic Surgery, 55, 822-829. doi:10.1016/0003-4975(93)90098-3
[21] Shangrow, R.F. (1993) Splanchnic, hepatic and visceral effects. In: Gravlee, G.P., David, R.F., et al., Cardiopulmonary bypass: Principles and practice. Williams et Wilkins, Baltimore.
[22] Hanks, J.B., Curtis, S.E., Hanks, B.B., et al. (1982) Gastrointestinal complications after cardiopulmonary bypass. Surgery, 92, 394.
[23] Munakata, A., Aisawa, T., Yoshida, Y., et al. (1987) Prospective study of acute gastric mucosal lesion in patients receiving open heart surgery under extracorporeal circulation. Gastrointestinal Endoscopy, 33, 151.
[24] Gon, S., Irie, Y. and Takahashi, M. (2006) Effects of rabeprazole or famotidine during cardiac surgery on perioperative gastric and esophageal pH readings. Japanese Journal of Thoracic and Cardiovascular Surgery, 54, 278-284. doi:10.1007/PL00022253
[25] Wagner, B.K., Amory, D.W., Majcher, C.M., DiFazio, L.T., Scott, G.E. and Spotnitz, A.J. (1995) Effects of intravenous famotidine on gastric acid secretion in patients undergoing cardiac surgery. The Annals of Pharmacotherapy, 29, 349-453.
[26] Zacharias, A., Schwann, T.A., Parenteau, G.L., Riordan, C.J., Durham, S.J., Engoren, M., Fenn-Buderer, N. and Habib, R.H. (2000) Predictors of gastrointestinal complications in cardiac surgery. Texas Heart Institute Journal, 27, 93-99.
[27] Aouifi, A., Piriou, V., Bastien, O., et al. (1999) Severe digestive complications after heart surgery using extracorporeal circulation. Canadian Journal of Anesthesia, 46, 114-121. doi:10.1007/BF03012544
[28] Bolcal, C., Iyem, H., Sargin, M, Mataraci, I., Sahin, M.A., Temizkan, V., Yildirim, V., Demirkilic, U. and Tatar, H. (2005) Gastrointestinal complications after cardiopulmonary bypass: Sixteen years of experience. Canadian Journal of Gastroenterology, 19, 613-617.
[29] Jayaprakash, A., McGrath, C., McCullagh, E., Smith, F., Angelini, G. and Probert, C. (2004) Upper gastrointestinal haemorrhage following cardiac surgery: A comparative study with vascular surgery patients from a single centre. European Journal of Gastroenterology & Hepatology, 16, 191-194. doi:10.1097/00042737-200402000-00011
[30] Durham, R.M. and Shapero, M.J. (1991) Stress gastritis revisited. Surgical Clinics of North America, 71, 791-810.
[31] Della Ratta, R.K., Corapi, M.J., Horowitz, B.R. and Calio, A.J. (1993) Risk of postoperative upper gastrointestinal tract hemorrhage in patients with active peptic ulcer disease undergoing nonulcer surgery. Archives of Internal Medicine, 153, 2141-2144. doi:10.1001/archinte.153.18.2141
[32] Chigot, J.P., Bitker, M., Chalgadian, R., et al. (1981) Abdominal complication of heart surgery. Archives des Maladies du Coeur et des Vaisseaux, 74, 665-673.
[33] Kalz, S.E., Kornfeld, D.S., Harris, P.D. and Yeoh, C.B. (1972) Acute gastrointestinal ulceration with open heart surgery and aortic valve disease. Surgery, 72, 438-442.
[34] Lebovics, E., Lee, S.S., Dworkin, B.M., et al. (1991) Upper gastrointestinal bleeding following open heart surgery. Digestive Diseases and Sciences, 36, 757-760. doi:10.1007/BF01311233
[35] Halm, U., Halm, F., Thein, D., Mohr, F.W. and Mossner, J. (2000) Helicobacter pylori infection: A risk factor for upper gastrointestinal bleeding after cardiac surgery? Critical Care Medicine, 28, 110-113. doi:10.1097/00003246-200001000-00018
[36] Poirier, B., Baillot, R., Bauset, R., Dagenais, F., Mathieu, P., Simard, S., Dionne, B., Caouette, M., Hould, F.S., Doyle, D. and Poirier, P. (2003) Abdominal complications associated with cardiac surgery. Review of a contemporary surgical experience and of a series done without extracorporeal circulation. Canadian Journal of Surgery, 46, 176-182.
[37] Díaz-Gómez, J.L., Nutter, B., Xu, M., Sessler, D.I., Koch, C.G., Sabik, J. and Bashour, C.A. (2010) The effect of postoperative gastrointestinal complications in patients undergoing coronary artery bypass surgery. The Annals of Thoracic Surgery, 90, 109-115. doi:10.1016/j.athoracsur.2010.03.062
[38] Huddy, S.P., Joyce, W.P. and Pepper, J.R. (1991) Gastrointestinal complications in 4473 patients who underwent cardiopulmonary bypass surgery. British Journal of Surgery, 78, 293-296. doi:10.1002/bjs.1800780309
[39] Ball, G.B. and Grap, M.J. (1992) Postoperative GI symptoms in cardiac surgery patients. Critical Care Nurse, 12, 56-62.
[40] Geissler, H.J., Fischer, U.M., Grunert, S., Kuhn-Régnier, F., Hoelscher, A., Schwinger, R.H., Mehlhorn, U. and Hekmat, K. (2006) Incidence and outcome of gastrointestinal complications after cardiopulmonary bypass. Interactive CardioVasc Thoracic Surgery, 5, 239-242. doi:10.1510/icvts.2005.117382
[41] Cook, D.J., Gayatt, G.H., Salena, B.J., et al. (1992) Endoscopic therapy for acute non variceal haemorrhage: A meta-analysis. Gastroenterology, 102, 139-148.

Copyright © 2023 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.