Management of Curling's Ulcer

Immediate Prophylactic Management

The American College of Critical Care Medicine recommends initiating stress ulcer prophylaxis immediately with either proton pump inhibitors (PPIs) or H2-receptor antagonists (H2RAs), combined with early enteral nutrition when feasible, in all critically ill burn patients with risk factors for gastrointestinal bleeding 1, 2
Curling's ulcers develop within 24-48 hours after severe thermal injury, particularly in patients with burns >40% total body surface area 2
The strongest predictors requiring prophylaxis include mechanical ventilation >48 hours 1, 2, coagulopathy (OR = 4.3 for GI bleeding) 2, and hypovolemic shock causing gastric hypoperfusion 2
The Surviving Sepsis Campaign guidelines recommend either PPIs or H2RAs for stress ulcer prophylaxis in critically ill patients with risk factors (strong recommendation, low quality evidence) 1

Initiate early enteral feeding as soon as hemodynamically stable, providing 20-25 kcal/kg daily during early catabolic phase 3, 4
Advance to 25-30 kcal/kg daily during recovery phase 3, 4

If bleeding develops despite prophylaxis, target systolic blood pressure 90-100 mmHg (permissive hypotension strategy) and maintain hemoglobin >7 g/dL (restrictive transfusion strategy) 5
Correct coagulopathy immediately and normalize lactate and base deficit 5
Urgent endoscopy (<12 hours) is first-line for diagnosis and treatment, with dual-modality endoscopic hemostasis for active bleeding 5
Administer IV PPI bolus followed by continuous infusion for 72 hours post-hemostasis 2, 5

Daily assessment for occult bleeding: monitor hemoglobin, check for melena/hematemesis 2

Delaying prophylaxis: must start immediately upon admission, not after bleeding develops 2
Inadequate enteral nutrition: early feeding provides independent protection beyond acid suppression 1, 2
The mortality from stress ulcer bleeding in critically ill patients reaches 48.5% compared to 9.1% in those without bleeding, emphasizing the critical importance of aggressive prophylaxis 2