Also Known as Stress Ulceration or Stress-Induced Gastritis

By Ashley Olivine, Ph.D., MPH 

 Medically reviewed by Jane Kim, MD

An ulcer is broken skin or tissue, or an open sore, that is usually accompanied by inflammation or infection.1 Stress ulcers are composed of damaged tissue caused by stress in certain areas of the gastrointestinal tract, the series of hollow organs through which food enters the mouth and travels through the body to be digested.

Learn more about stress ulcers, what they are and what they are not, how they form, symptoms, and more.

Jose Luis Pelaez / Getty Images

Stress Ulcers: What They Are

Stress ulcers are open sores found in certain areas of the digestive tract. They are caused by physical stress on the body, such as the kind that may lead to hospitalization or that occur during hospitalization.2 Extreme levels of physical stress from something like a severe injury or major surgery can lead to other physical changes in the body that lead to ulcers.

This condition is often confused with three similar conditions, which are:

• Peptic ulcers: A sore that occurs on the lining of the esophagus, stomach, or small intestine

• Gastritis: A condition characterized by inflammation of the stomach lining

• Gastropathy: Diseases that affect the mucosal lining of the stomach

These terms are sometimes used interchangeably.

Stress Ulcers: What They Are Not

Stress ulcers, peptic ulcers, gastritis, and gastropathy all affect the lining of the stomach. Additionally, they have overlapping symptoms and can occur at the same time.3 However, there are differences among these conditions.

Stress Ulcers vs. Peptic Ulcers

Peptic ulcers, also called stomach ulcers, are open sores in the stomach, in the esophagus (which is just above the stomach), or in the duodenum (which is just below the stomach).4

The primary difference between a stress ulcer and a peptic ulcer is what causes them. Unlike stress ulcers, which are caused by high levels of physical stress such as physical trauma or surgery, peptic ulcers are caused by a bacterium called Helicobacter pylori, among other possibilities. While stress can make peptic ulcers worse, stress is not the cause.

Causes of peptic ulcers include:

• Helicobacter pylori (H. pylori), a bacterial infection

• Taking nonsteroidal anti-inflammatory drugs (NSAIDs) for a long time

• Stomach cancer tumors

• Tumors in the stomach that are not cancerous

Stress Ulcers vs. Gastritis

Gastritis is similar to a stress ulcer in that they both involve irritation in the digestive tract and the lining of the stomach. They may also have similar symptoms, such as pain in the upper abdomen. However, they are different conditions.

Gastritis involves inflammation, which can be increased redness, swelling, and pain, whereas an ulcer is an open sore or damaged tissue.5 Gastritis can also lead to peptic ulcers.3

Stress Ulcers vs. Gastropathy

Like gastritis, gastropathy is similar to stress ulcers in that they are both irritations that affect the stomach lining. Gastropathy, however, causes damage to the lining of the stomach.5 Additionally, gastropathy can lead to peptic ulcers.3

Gastritis vs. Gastropathy

Gastritis and gastropathy are both conditions that involve irritation to the lining of the stomach. The difference between them is that gastritis is characterized by an inflamed stomach lining, or pain, redness, and swelling without damage to the tissue, whereas gastropathy is a damaged stomach lining with little or no inflammation.

How Stress Ulcers Form

Some estimate that 75% percent of people admitted to hospital intensive care units (ICUs) who are not receiving preventive care for stress ulcers may develop asymptomatic stress ulcers, but a much lower percentage have clinically significant bleeding.2

When a person experiences critical illness or hospitalization, there are physical effects on the body. Stomach acid levels can increase and the lining of the stomach—also called the mucosa—can be damaged.2 It can also impact the duodenum, which is just below the stomach and where food is additionally digested after leaving the stomach. As the mucosal lining deteriorates, stress ulcers begin to form.

Physical stress such as physical trauma or surgery can lead to changes in:

• Stomach acid levels

• Stomach lining damage

• Other areas of the digestive tract

Stress Ulcer Causes

Types of physical stress that can turn into stress ulcers include:

• Bodily trauma

• Brain injury

• Burns

• Hemorrhage

• Injury

• Sepsis

• Shock

• Surgery

Who Is at Risk?

While anyone in the ICU or hospital setting can develop a stress ulcer, some people are at a greater risk of getting them and experiencing complications such as significant bleeding. Risk factors include:6

• Problems with platelets (blood cells)

• Being on a ventilator

• History of ulcer or bleeding within the last year

• Traumatic brain injury

• Being on NSAIDs or antiplatelet agents (especially some heart disease patients)

Where a Stress Ulcer Is Found

Stress ulcers are found in the gastrointestinal tract. Most stress ulcers occur in the lining of the stomach—more specifically, in the middle or top regions of the stomach. However, they can also occur in the esophagus, in the lower part of the stomach, or in the duodenum.7

Types of Stress Ulcers

The types of stress ulcers are related to the types of physical stress that causes them. While many different physical stressors can lead to stress ulcers, not all of these causes have names. Curling ulcers and Cushing ulcers are two types of stress ulcers caused by different physical stressors, and they are:7

• Curling ulcers are a type of stress ulcer that is caused by systemic burns, or burns that impact 30% of the body or more.

• Cushing ulcers are a type of stress ulcer that is caused by acute traumatic brain injury.

Stress Ulcer Symptoms

The stress ulcer that is most common among people who are critically ill is bleeding that comes from the upper part of the gastrointestinal tract.7 This can be seen when a person vomits blood or when the stool looks black from blood. Symptoms that are less severe include pain in the stomach region and nausea.

The following can all be symptoms of stress ulcers:

• Blood in vomit

• Blood in stool that looks black

• Fainting and light-headedness

• Pain after eating, feeling full or bloated, or upper abdominal pain

• Low blood pressure when standing up

• Pale skin

• Vomit that looks like coffee grounds

Diagnosis and Treatment

Stress ulcers can be diagnosed with a procedure called an endoscopy. This is when a medical device made up of a long tube with a light and camera is placed into the stomach through the mouth.

Once diagnosed, stress ulcers can be treated with medications. Additionally, medications called proton pump inhibitors, which decrease stomach acid, are sometimes given to people in ICUs to prevent stress ulcers.8

Summary

A stress ulcer is an open sore in the lining of the stomach or surrounding area that is caused by extreme, physical stress. They are often confused with peptic ulcers, gastritis, and gastropathy, but these similar conditions have differences.

Stress ulcers form when physical stress changes acid levels in the stomach, which damages the lining of the stomach.

There are different types of stress ulcers, including Curling ulcers seen in people with severe burns and Cushing ulcers seen in people with severe brain injury. Symptoms include stomach pain, vomiting, and bleeding.

Sources

Harvard Medical School. Medical dictionary of health terms: Ulcer.

Kerama SK, Okalebo FA, Nyamu DG, Guantai EM, Ndwigah SN, Maru SM. Risk factors and management of stress ulcers in the critical care unit in a Kenyan referral hospital. African Journal of Pharmacology and Therapeutics. 2014;3(2).

National Institutes of Health. Definition & facts for gastritis & gastropathy.

National Institutes of Health. Definition & facts for peptic ulcers.

National Institutes of Health. Gastritis & gastropathy.

Krag M, Perner A, Wetterslev J, et al. Prevalence and outcome of gastrointestinal bleeding and use of acid suppressants in acutely ill adult intensive care patients. Intensive Care Med. 2015;41(5):833-45. doi:10.1007/s00134-015-3725-1

Siddiqui AH, Farooq U, Siddiqui F. Curling Ulcer. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021.

Madsen KR, Lorentzen K, Clausen N, Oberg E, Kirkegaard PR, Maymann-Holler N, Moller MH. Guideline for stress ulcer prophylaxis in the intensive care unit. Dan Med J. 2014;61(3):C4811.

By Ashley Olivine, Ph.D., MPH
Dr. Ashley Olivine is a health psychologist and public health professional with over a decade of experience serving clients in the clinical setting and private practice. She has also researched a wide variety psychology and public health topics such as the management of health risk factors, chronic illness, maternal and child wellbeing, and child development.