J.Jpn. Surg. Soc.. 58(11): 1809-1830, 1958

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GASTROINTESTINAL COMPLICATIONS UNDER VARIOUS KINDS OF PHYSICAL STRAINS AND POSTOPERATIVE RESPONSE OF URINARY PEPSINOGEN EXCRETION.

Gastrointestinal complications (esp. ulceration and hemorrhage) under induced stress in men and animals have been not infrequently reported by a number of observers since the end of the last century. The author collected 17 cases with the complications of gastrointestinal tract under various kinds of physical strains in the First Surgical Department, Tokyo University.
Primary lesions, inducing stress-condition, included intracranial tumor, inflammation, head injury, various kinds of neurosurgical procedures, and extensive burns. Besides the ulceration and hemorrhage, gastrointestinal paresis might be considered as one of the gastrointestinal complications under stress. Gastrointstinal hemorrhage and ulceration were found mostly in cases under acute strese, and gastrointestinal paresis without any sign of diffuse peritonitis were found mostly in cases under chronic stress, such as a long-standing infection (except a case with bilateral cingulectomy). Occasionally, it was a kind of difficult problem to check the occurrence of these complications in those severely ill patients. The clinical findings, pathogenesis and treatment were discussed.
In the review of autopsies, pathological findings of adrenal glands (hemorrhage, necrosis, hyperplasia etc.) were demonstrated not infrequently. A demonstrable case, with perforated duodenal ulcer after severe head injury, showed typical adrenal hemorrhage and petechial hemorrhage in hypothalamic region.
The two physiologic pathways by which the stomach might be stimulated to secrete pepsinogen and hydrochloric acid are mediated by the release of Gastrin and by way of the vagus nerve. Recently, not a few studies have demonstrated a third phase of gastric secretion under adrenal cortical control. Stress is mediated to the stomach by the neurogenic pathway through the anterior hypothalamus and vagus nerve resulting in alteration in the motility, secretion and vascularity of the stomach. However, the importance of other influences through the hypothalamic-pituitary-adrenal-gastric pathway, having been described by Gray et al., might be emphasized.
The gastric response to adrenal stimulation could be determined by measuring the urinary pepsinogen (Uropepsin, Gray et al.). The author checked postoperative response of the output of urinary pepsinogen, measured by the modified Hirschowitz's method in a group of varous kinds of surgical patients (abdominal, endocrinological, neurological surgery etc.). Acute physical stress induced a significant response in the output of urinary pepsinogen of a few postoperative days after having any kind of major surgery.A definite correlation between the urinary pepsinogen excretion and urinary adrenal .corticoids excretion was found in the pre-and postoperative period of a case with Cushing'ssyndrome.
The etiology of acute gastric ulcers and hemorrhage developing during various kinds of stress might be in part, at least on the basis of increased adrenal activity, since these severe stressors are known to, produce excessive ACTH and corticords output and, at the same time, increased gastric secretion which can be demonstrated by showing increased output of urinary pepsinogen. Gastrointestinal (submucosal) hemorrhage and paresis might be due to dysharmonized function of the autonomic nervous system.
(author's abstract)

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