Fast diagnosis and successful management of stress-induced ulcer with hemorrhagic shock following staging surgery for ovarian cancer: a case report

Introduction

Background

Ovarian cancer (OC) is a common gynecologic malignancy, and postoperative management is crucial. Stress ulcers (SU), also known as stress-related mucosal disease, are a manifestation of gastrointestinal dysfunction in the body under severe trauma, critical illness, or significant psychological distress (1). They are acute mucosal erosive ulcers that occur in the stomach, duodenum, or esophagus during stress states. Common manifestations include bleeding, which can further worsen to massive bleeding and perforation, clinically presenting as upper gastrointestinal bleeding, melena, and sometimes even hematemesis and hypovolemic shock, leading to deterioration of the underlying condition, increased length of hospital stay, higher medical costs, and increased mortality (2,3). The incidence of SU is usually related to the severity of the patient’s condition, especially during surgery, trauma, infection, or other major illnesses, where increased gastric acid secretion and impaired gastric mucosal barrier significantly elevate the risk of ulceration (4). Additionally, psychological stress and anxiety are also considered closely related to the occurrence of SU, particularly in patients undergoing major surgeries or severe illnesses (5). In certain high-risk populations, such as patients on long-term anticoagulation therapy, the incidence of SU bleeding may be even higher (6). Clinically, H₂ receptor antagonists, proton pump inhibitors, antacids, or gastric mucosal protectants are commonly used for the prevention or treatment of SU. Research statistics show that 75% to 100% of critically ill patients will experience gastric mucosal injury (7), with approximately 2.6% of patients further developing SU (8). Once stress ulcer bleeding (SUB) occurs, the mortality rate can be as high as 48.5% to 65% (9). Another study indicated that patients receiving prophylaxis for SU in the intensive care unit (ICU) had significantly lower mortality rates (10). Therefore, timely identification and prevention of SU are crucial for improving the prognosis of critically ill patients.

Rationale and knowledge gap

Cases of hemorrhagic shock caused by SU after OC surgery have not been reported yet. While it is known that SU is associated with multiple factors such as surgical trauma, stress response, and underlying medical conditions, the exact mechanisms by which these factors interact in the context of OC patients remain unclear. There is a lack of comprehensive research on the optimal preventive and treatment strategies specifically tailored to OC patients, especially considering the unique physiological and treatment-related factors in this patient population.

Objective

This article reports on the early identification, diagnosis, early intervention, and standardized treatment process of a patient who developed SU leading to massive bleeding and hemorrhagic shock after undergoing comprehensive staging surgery for OC, ultimately achieving a good prognosis. Additionally, through a comprehensive analysis of existing literature, it provides an in-depth understanding of these conditions and offers references for clinical practice. We present this article in accordance with the CARE reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-43/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the editorial office of this journal.

The patient was a 56-year-old female who was diagnosed with pelvic malignancy via laparoscopic biopsy at West China Second University Hospital of Sichuan University on July 17, 2023, and subsequently received three cycles of intravenous neoadjuvant chemotherapy with a paclitaxel and carboplatin regimen. The patient was readmitted on October 2, 2023, and underwent comprehensive staging surgery for OC on October 7, during which she lost 2,000 mL of blood and received 4.5 U of red blood cells and 600 mL of plasma. Based on the medical history, intraoperative findings, and postoperative pathology results, she was diagnosed with poorly differentiated adenocarcinoma of the ovary (T3N0M0). Postoperatively, she was kept NPO and received parenteral nutrition, antibiotic prophylaxis for infection, lower limb pneumatic therapy, and subcutaneous low molecular weight heparin (LMWH) 4,000 IU qd to prevent deep vein thrombosis. Table 1 provides changes in coagulation function during the patient’s hospitalization.

On the fourth postoperative day, the patient began experiencing abdominal distension, diarrhea (over 12 loose stools), and vomiting, while other vital signs remained stable. An abdominal X-ray indicated multiple tubular and linear shadows in the overlapping abdominal and pelvic areas; small bowel distension and gas accumulation were noted in the upper left abdomen, with a small gas-liquid level seen in the right upper quadrant, but no definite signs of bowel wall gas or significant free air or fluid in the abdominal cavity were observed. Considering the possibility of partial bowel obstruction, gastrointestinal decompression was performed, and the patient’s symptoms slightly improved. On the sixth postoperative day, the patient reported abdominal distension but no diarrhea; a repeat abdominal X-ray showed similar findings, with gas in the bowel without significant dilation. The diagnosis of partial bowel obstruction was considered, and gastrointestinal decompression and supportive treatment were continued. On the ninth postoperative day, dark red bloody drainage was noted in the gastric tube, raising suspicion for upper gastrointestinal bleeding. The patient was treated with omeprazole 40 mg intravenous (IV), octreotide 0.6 mg q24h via IV pump for acid suppression, and colloidal bismuth for gastric protection. On the morning of the eleventh postoperative day, the patient suddenly experienced dizziness, blurred vision, profuse sweating, cold and clammy extremities, and a drop in blood pressure (as low as 50+/30+ mmHg), with a heart rate of 78 beats/min and oxygen saturation (SpO₂) at 96% (deoxygenated). Cardiac ultrasound, electrocardiogram (ECG), chest and abdominal ultrasound, and bilateral lower limb venous ultrasound showed no abnormalities. Hemoglobin was 91 g/L (124 g/L on postoperative day 9). Considering acute upper gastrointestinal bleeding complicated by hemorrhagic shock, LMWH was immediately discontinued, and rapid intravenous fluid resuscitation, continuous gastrointestinal decompression, omeprazole 40 mg IV, somatostatin infusion, and thrombin lyophilized powder tube feeding were administered, leading to symptom relief. On the twelfth postoperative day, the patient passed dark brown watery stools totaling 1,674 mL, with no other special discomfort, and was discharged smoothly on the twentieth postoperative day. A timeline of the case evolution is presented in Table 2.

Discussion

In this case, the SU that led to hemorrhagic shock was likely caused by multiple factors. Combining domestic and international literature with the characteristics of this case, we will discuss them one by one. The occurrence of SU is closely related to various factors, including neuroendocrine dysregulation, weakened gastric mucosal protective function, enhanced factors damaging the gastric mucosa, oxidative damage from free radicals, and gastric mucosal lesions (11,12). Factors influencing the occurrence of SU include age, underlying diseases, type of surgery, medications used (such as non-steroidal anti-inflammatory drugs and anticoagulants), and levels of psychological stress (13). In the presence of SU risk factors for massive bleeding from SU often include mechanical ventilation for more than 48 hours or extracorporeal life support, coagulation disorders, a history of pre-existing gastrointestinal ulcers or bleeding, extensive use of glucocorticoids or concurrent use of non-steroidal anti-inflammatory drugs, severe cranial, cervical spinal injuries, severe burns, major trauma, complex surgeries, sepsis, multiple organ dysfunction syndrome (MODS), and shock (14). In this case, the patient had no history of gastric ulcers prior to admission, and the colonoscopy performed three months prior showed no abnormalities. However, the patient underwent three cycles of neoadjuvant chemotherapy before the comprehensive staging surgery for OC. Chemotherapy drugs are highly cytotoxic, and the possibility of gastric mucosal injury during chemotherapy cannot be ruled out, which may disrupt the normal gastric mucosal defense mechanism. When faced with sudden changes in hormone levels, it is easier to induce lesions, potentially extending to surrounding and deeper blood vessels, leading to massive bleeding. Critically ill patients undergoing surgery, infection, or trauma experience increased gastric acid secretion and impaired gastric mucosal barrier, significantly raising the risk of ulceration. After completing three cycles of neoadjuvant chemotherapy, the patient underwent comprehensive staging surgery for OC, which involved a wide surgical field and significant blood loss (2,000 mL). In this stress state, neuroendocrine dysregulation may occur, while gastric mucosal protective function weakens, and factors damaging the gastric mucosa are relatively enhanced, leading to pathological and physiological changes in the gastric mucosa and subsequent damage. Additionally, psychological stress and anxiety are also considered closely related to the occurrence of SU (5), particularly in patients undergoing major surgeries or severe illnesses. Furthermore, the patient was NPO for an extended period postoperatively; according to research by Becq et al. (15), enteral feeding may have a protective effect against postoperative SU bleeding (16).

SU are relatively common in clinical practice, but reports of massive bleeding leading to hemorrhagic shock from postoperative SU are relatively rare. Risk factors about SU in ill patients include mechanical ventilation, coagulation disorders, burns, renal failure, and neurological injuries (17). The probability of developing SU varies among different populations. In certain high-risk groups, such as patients on long-term anticoagulation therapy, the incidence of SU bleeding may be higher (6). Clinically, H2 receptor antagonists, proton pump inhibitors, antacids, or gastric mucosal protectants are commonly used for the prevention or treatment of SU (18). Antacids alleviate gastric mucosal irritation by neutralizing gastric acid and are often used for mild gastric acid-related symptoms. Studies have shown that antacids can effectively relieve symptoms in the short term, but their effectiveness in preventing SU is limited. Proton pump inhibitors provide stronger protective effects by inhibiting gastric acid secretion, especially suitable for high-risk patients (18). Multiple studies have shown that proton pump inhibitors (PPIs) have a significant effect on preventing the occurrence of SU in intensive care units, and their efficacy is more prolonged compared to antacids (19). In this case, dark red bloody drainage was observed in the gastric tube on the ninth postoperative day, and a surgical consultation considered the possibility of stress-related gastric mucosal bleeding; therefore, acid suppression and gastric protection measures were taken. However, prior to this, adequate gastric mucosal protective measures were not implemented, and the patient should have been identified for high-risk factors and received preventive medication for SU earlier.

The second leading cause of death in cancer patients is venous thromboembolism (VTE) (20). LMWH is effective in anticoagulation (21). Due to its long half-life and high bioavailability, LMWH is widely used in clinical anticoagulation therapy (21). In the treatment of surgical and medical cancer patients, LMWH is the most commonly used preventive measure, with usage rates of 74.2% and 80.6% (22), respectively. Another study emphasized that the use of LMWH in cancer patients undergoing major surgery is positively correlated with the risk of postoperative bleeding (23). For this malignant tumor patient, the postoperative VTE score was 5, so LMWH was typically started on the first postoperative day to prevent deep vein thrombosis. However, in clinical practice, cases of gastrointestinal massive bleeding induced by anticoagulants are not uncommon. For example, one study (24) reviewed patients who experienced gastrointestinal massive bleeding during anticoagulant therapy and found that these patients still faced a risk of rebleeding after stopping anticoagulation therapy. Additionally, certain special populations, such as elderly patients and those with a history of gastrointestinal bleeding, have a higher risk of massive bleeding (25).

This is a report of a case involving acute massive hemorrhage due to anticoagulation therapy following staging surgery for OC. The patient’s underlying diseases, types and doses of anticoagulants, and other concomitant medications can all affect the occurrence and severity of bleeding. Therefore, clinicians should fully assess the bleeding risk when using anticoagulants and develop personalized anticoagulation plans to reduce the incidence of gastrointestinal bleeding. Close monitoring of coagulation levels is also essential. If bleeding tendency is suspected, anticoagulants should be stopped immediately, and rescue medications such as warfarin and vitamin K should be administered promptly.

This study details a case of an OC patient who developed SU and hemorrhagic shock subsequent to staging surgery, thereby filling a notable gap in the existing literature. It offers invaluable insights for clinicians, enabling them to deepen their comprehension of analogous cases. The case vividly demonstrates the capacity to promptly identify SU post-operatively and implement timely and efficacious interventions, such as intravenous fluid resuscitation and acid-suppression therapy, to improve the patient’s prognosis, thus underscoring the significance of early intervention. Our research not only thoroughly analyzed this case but also comprehensively synthesized relevant literature. We systematically reviewed the definition, epidemiology, etiology, clinical manifestations, and treatment modalities of SU, furnishing readers with a more all - encompassing perspective and facilitating a better understanding of this condition. Furthermore, our study probed into diverse potential factors contributing to the onset of SU, including neuroendocrine dysregulation, the impacts of chemotherapy drugs, and surgical stress, providing crucial information for clinicians in risk assessment and management. Notwithstanding, this study is grounded solely in the clinical experience of a single patient and lacks statistical data from a large-scale sample. This restricts the generalizability of the findings and may impede their broad application to other similar cases.

Conclusions

This case report describes a 56-year-old female who developed SU and hemorrhagic shock after OC staging surgery. Timely intravenous fluid resuscitation and acid suppression led to a good prognosis. It underscores the importance of vigilance for SU in postoperative care, especially after major abdominal surgeries. The case highlights the multifactorial etiology of SU and the critical need for early identification and standardized treatment. Despite its single-case nature, it provides valuable insights for clinical practice. Future research should focus on developing standardized protocols for prevention and management to improve outcomes in postoperative patients.

Acknowledgments

We would like to extend our greatest thanks to this female patient for trusting her care with us and allowing us to share her story.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-43/rc

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-43/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-43/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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