Search
stress ulceration
A common cause of upper gastrointestinal bleed in intensive care unit (ICU) patients.
Etiology:
Risk factors:
- head injury
- major trauma
- shock, multi-organ failure
- hypotension
- burns > 25% of body area
- sepsis
- respiratory failure*
- mechanical ventilation > 48 hours
- coagulopathy*
- blood platelets < 50,000/uL
- INR > 1.5
- CNS disease
- intracranial hypertension
- spinal cord injury
- quadriplegia
- extended ICU stay
- liver failure
- renal failure
* major risk factors [2] (4% vs 0.1% without risk factors) thus overall risk is low; respiratory failure requiring mechanical ventilation for > 2 days
Pathology:
1) gastric acid is critical component
2) hypersecretion of acid is uncommon except in patients with head injury
3) gastric mucosal blood flow is altered
4) disruption of gastric mucosa with erosions, ulceration & hemorrhage
5) shallow ulcerations in the gastric fundus are ubiquitous in critically ill patients
Management:
- prophylaxis:
1) indications
a) prolonged mechanical ventilation
b) coagulopathy
2) pharmaceutical agents
a) H2-receptor antagonists
1] effective for prophylaxis of stress ulceration
2] but may increase risk of pneumonia
b) sucralfate
- may reduce risk of pneumonia & death
c) antacids
3) no therapy has proven efficacy in decreasing mortality [2]
General
gastric ulcer
References
- Manual of Medical Therapeutics, 28th ed, Ewald &
McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 352
- Medical Knowledge Self Assessment Program (MKSAP) 11, 15,
American College of Physicians, Philadelphia 1998, 2009
- Prescriber's Letter 14(1): 2007
Stress Ulcer Prophylaxis
Detail-Document#: 230112
(subscription needed) http://www.prescribersletter.com