Case Report Open Access
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Nov 16, 2020; 12(11): 500-503
Published online Nov 16, 2020. doi: 10.4253/wjge.v12.i11.500
Curling ulcer in the setting of severe sunburn: A case report
Alexander Schosheim, Michelle Tobin, Anupama Chawla, Department ofPediatric Gastroenterology , Stony Brook University Hospital , Stony Brook, NY 11794, United States
ORCID number: Alexander Schosheim (0000-0002-8651-2554); Michelle Tobin (0000-0003-1449-6855); Anupama Chawla (0000-0002-9960-540X).
Author contributions: Schosheim A, Tobin M and Chawla A contributed equally to this work. Schosheim A, Tobin M, and Chawla A conceptualized and drafted the initial manuscript, and reviewed and revised the manuscript along with also critically reviewing the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Informed consent statement: Informed verbal consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: There are no conflicts of interest. 
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the creative commons attribution noncommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Alexander Schosheim, MD, Pediatric Gastroenterology Fellow, Department of Pediatric Gastroenterology, Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY 11794, United States. aschosheim@gmail.com
Received: August 3, 2020
Peer-review started: August 3, 2020
First decision: September 17, 2020
Revised: September 30, 2020
Accepted: October 20, 2020
Article in press: October 20, 2020
Published online: November 16, 2020
Processing time: 104 Days and 23.2 Hours

Abstract
BACKGROUND

While sunburns are very common, especially in pediatrics, curling ulcers secondary to sunburns are a very rare entity that has not been noted in the literature in over fifty years. This case is the first addition to the literature since the originally documented case.

CASE SUMMARY

A previously healthy 17 year old male presents to the emergency room with lethargy, shortness of breath on exertion, dark stools and nausea. His fatigue started to become significantly worse four days prior to admission. Approximately two weeks prior to admission, the patient was on a beach vacation with his family at which time he suffered severe sunburns. He had developed crampy epigastric abdominal pain, which was followed by dark, loose stools. On exam, he is non-toxic appearing, but with pallor and peeling skin on his face and chest with epigastric tenderness. Infectious stool studies were all negative including Helicobacter pylori. He denies use of any non-steroidal anti-inflammatory drugs and also denies alcohol or recreational drug use. While admitted he is found to be significantly anemic with his hemoglobin as low as 6.3 requiring two units of packed red blood cells. Endoscopy revealed several severe and deep ulcerations in the antrum and body of the stomach indicative of stress or curling ulcers.

CONCLUSION

While the incidence of stress ulcers is not known, it is most common with severe acute illness, most commonly presenting as upper gastrointestinal (GI) bleeding. It is essential to be aware of the risk of curling ulcers secondary to severe sunburns as patients with stress ulcer GI bleeding have increased morbidity and mortality compared to those who do not have GI bleed.

Key Words: Curling ulcer; Sunburn; Stress ulcer; Pediatrics; Gastroenterology; Gastrointestinal bleed; Case report

Core Tip: While sunburns are very common, especially in pediatrics, curling ulcers secondary to sunburns are a very rare entity that has not been noted in the literature in over fifty years. Although a very rare consequence of sunburn, it is essential to be aware of the risk of curling ulcers secondary to severe sunburns as patients with stress ulcer gastrointestinal bleeding have increased morbidity and mortality compared to those who do not have gastrointestinal bleed.



INTRODUCTION

Stress ulcers are a well-known clinical entity with various findings ranging from asymptomatic superficial lesions and occult gastrointestinal (GI) bleed to overt clinically significant GI bleeding. It is thought that this is typically due to gastric and sometimes esophageal or duodenal mucosal barrier is disruption[1]. When the etiology of the stress ulcer is a burn, they are characterized as curling ulcers. Most cases of curling ulcers in the current literature are secondary to severe systemic burns and although rare, there was one previous case report of curling ulcer secondary to sunburn[2].

CASE PRESENTATION
Chief complaints

A previously healthy 17 year old male presented to Stony Brook University Hospital from an outside hospital with lethargy, shortness of breath on exertion, dark stools and nausea.

History of present illness

The patient's fatigue had become significantly worse for four days prior to admission. Approximately two weeks prior to admission, the patient was on a beach vacation with his family at which time he suffered severe sunburns. He had developed crampy epigastric abdominal pain that was followed by dark, loose stools. 

History of past illness

He has no significant past medical history. 

Personal and family history

He and his family have no significant history. 

Physical examination

On physical exam, he was pale and tired-appearing with epigastric tenderness. 

Laboratory examinations

Infectious stool studies were all negative including Helicobacter pylori. His complete blood count revealed that he was significantly anemic with a hemoglobin of 6.3 and his complete metabolic panel was within normal limits. 

Imaging examinations

No imaging was performed. 

Further hospital course

Endoscopy was performed and revealed severe, deep ulcerations in the antrum and body of the stomach (Figure 1).

Figure 1
Figure 1 Deep ulcerations in the antrum of the stomach.
FINAL DIAGNOSIS

Curling ulcers in the antrum.

TREATMENT

The patient was treated with high dose proton-pump inhibitor and carafate along with iron and folate supplementation.

OUTCOME AND FOLLOW-UP

With time, the patient’s symptoms and blood work improved. Five months after his original admission, endoscopy was performed and all previous areas of ulceration had completely resolved.

DISCUSSION

While the incidence of stress ulcers is not known, it typically occurs with severe acute illness, most commonly presenting as upper GI bleeding. Although stress ulcers can lead to perforation, it is very rare with less than 1% incidence[3]. An impaired mucosal barrier where the mucosal glycoprotein breaks down due to increased concentrations of refluxed bile salts or uremic toxins in the setting of critical illness may be the possible pathologic changes that lead to ulceration. Increased secretion of gastric acid secondary to higher secretion of gastrin during stress is likely as well[4].

CONCLUSION

Curling ulcers secondary to sunburns are a previously described phenomenon, but it is a rare entity that has not been noted in the literature in over fifty years[2]. It is essential to be aware of the risk of curling ulcers secondary to severe sunburns as patients with stress ulcer GI bleeding have increased morbidity and mortality when compared to those without GI bleed.

Footnotes

Manuscript source: Unsolicited manuscript

Specialty type: Gastroenterology and hepatology

Country/Territory of origin: United States

Peer-review report’s scientific quality classification

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P-Reviewer: Armellini E, Toka B S-Editor: Zhang L L-Editor: A P-Editor: Wang LL

References
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