Stress ulcer bleeding

  • Richard F. Harty
  • Hari B. Ancha

Opinion statement

Although upper gastrointestinal (GI) bleeding from stress-related mucosal disease (SRMD) in critically ill patients is common, significant bleeding with hemodynamic instability is not. Risk factor assessment can assist in identifying patients with a greater likelihood of developing significant SRMD. Prophylaxis against stress ulcer bleeding with luminal agents (eg, antacids and sucralfate) or drugs that inhibit acid secretion (eg, histamine 2-receptor antagonists [H2RAs] and proton-pump inhibitors [PPIs]) can reduce major bleeding but has little or no effect on mortality. Currently, the mainstays of prophylactic therapy for SRMD are intravenously administered H2RAs and PPIs. Wider usage of PPIs reflects their enhanced efficacy in suppressing acid secretion as well as lack of tolerance for H2RAs. Guidelines for the prophylactic use of H2RAs or PPIs in treatment of SRMD will require large, randomized studies that also examine cost effectiveness of individual strategies.


Omeprazole Intensive Care Unit Patient Lansoprazole Misoprostol Esomeprazole 
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References and Recommended Reading

  1. 1.
    Spechler SJ: Peptic ulcer disease and its complications. In Gastrointestinal and Liver Disease, edn 7. Edited by Feldman M, Friedman LS, Sleisenger MH. Philadelphia: Saunders; 2002:747–781.Google Scholar
  2. 2.
    Haglund U: Stress ulcers. Scand J Gastroenterol 1990, 25(Suppl 175):27–33.Google Scholar
  3. 3.
    Lucas CE, Sugawa C, Riddle J, et al.: Natural history and surgical dilemma of "stress" gastric bleeding. Arch Surg 1971, 102:266–273.PubMedGoogle Scholar
  4. 4.
    Czaja AJ, McAlhany JC, Pruitt BA Jr: Acute gastroduodenal disease after thermal injury: An endoscopic evaluation of incidence and natural history. N Engl J Med 1974, 291:925–929.PubMedCrossRefGoogle Scholar
  5. 5.
    Hastings PR, Skillman JJ, Bushnell, et al.: Antacid titration in the prevention of acute gastrointestinal bleeding: a controlled, randomized trial in 100 critically ill patients. N Engl J Med 1978, 298:1041–1045.PubMedCrossRefGoogle Scholar
  6. 6.
    Cook DJ, Fuller HD, Guyatt GH, et al.: Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med 1994, 330:377–381. A large, prospective, randomized, multicenter study linking coagulopathy and respiratory failure in the causation of clinically significant upper GI bleeding in critically ill patients.PubMedCrossRefGoogle Scholar
  7. 7.
    Cook DJ, Reeve BK, Guyatt GH, et al.: Stress ulcer prophylaxis in critically ill patients. Resolving discordant meta-analysis. JAMA 1996, 275:308–314. Represents a critical review and analysis of a number of studies regarding stress ulcer prophylaxis.PubMedCrossRefGoogle Scholar
  8. 8.
    Tryba M, Cook DJ: Current guidelines on stress ulcer prophylaxis. Drugs 1997, 54:581–596.PubMedGoogle Scholar
  9. 9.
    Stollman N, Metz DC: Pathophysiology and prophylaxis of stress ulcer in intensive care unit patients. J Crit Care 2005, 20:35–45. A thoughtful review of factors contributing to stress ulcer bleeding, and a balanced approach to assessing treatment options.PubMedCrossRefGoogle Scholar
  10. 10.
    Spirt MJ: Stress-related mucosal disease. Curr Treat Options Gastroenterol 2003, 6:135–145. This article comprehensively reviews the pathophysiology and various controversies in the treatment of SRMD.PubMedCrossRefGoogle Scholar
  11. 11.
    Martindale RG: Contemporary strategies for the prevention of stress-related mucosal bleeding. Am J Health Syst Pharm 2005, 62(Suppl 2):S11-S17.PubMedGoogle Scholar
  12. 12.
    Zuckerman GR, Shuman R: Therapeutic goals and treatment options for prevention of stress ulcer syndrome. Am J Med 1987, 83(Suppl 6A):29–35.PubMedCrossRefGoogle Scholar
  13. 13.
    Chung LY, Ashley SW: Gastric blood flow and mucosal defense mechanisms. Clin Invest Med 1987, 10:201–208.Google Scholar
  14. 14.
    Cook D, Guyatt G, Marshall J, et al.: A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group. N Engl J Med 1998, 388:791–797.CrossRefGoogle Scholar
  15. 15.
    Kles KA, Wellig MA, Tappenden KA: Luminal nutrients exacerbate intestinal hypoxia in the hypoperfused jejunum. JPEN J Parenter Enteral Nutrition 2001, 25:246–253.CrossRefGoogle Scholar
  16. 16.
    Smith JS, Karlstadt R, Blatcher, et al.: Gastric pH from NPO to enteral-fed period with intermittent intravenous (IV) pantoprazole (P) vs continuously infused cimetidine (C). Am J Gastroenterol 2002, 97:S47.CrossRefGoogle Scholar
  17. 17.
    Hoogerwerf WA, Pasricha PJ: Pharmacotherapy of gastric acidity, peptic ulcers and gastroesophageal reflux disease. In Goodman & Gilman’s The Pharmacological Basis of Therapeutics, edn 11. Edited by Brunton LL, Lazo JS, Parker KL, et al. Columbus, OH: McGraw-Hill; 2006:1005–1020.Google Scholar
  18. 18.
    Otani Y, Kitajima M, Sugiyama M, et al.: Inhibitory effects of lansoprazole on gastric acid hypersecretion in patients with post operative stress. J Clin Gastroenterol 1995, 20(Suppl2):S22-S26.PubMedCrossRefGoogle Scholar
  19. 19.
    Levy MJ, Seelig CB, Robinson NJ, Ranney JE: Comparison of omeprazole and ranitidine for stress ulcer prophylaxis. Dig Dis Sci 1997, 42:1255–1259.PubMedCrossRefGoogle Scholar
  20. 20.
    Phillips JO, Metzler MH, Huckfeldt RE, et al.: A multicenter, prospective, randomized clinical trial of continuous infusion I.V. ranitidine vs omeprazole suspension in the prophylaxis of stress ulcers. Crit Care Med 1998, 26:A101.Google Scholar
  21. 21.
    Azevedo JR, Soares MG, Silva G, Palacio G: Prevention of stress ulcer bleeding in high risk patients: comparison of three drugs [abstract]. Crit Care Med 1992, 27:A41.Google Scholar
  22. 22.
    Hepburn B, Goldlust B: Comparative effects of an omeprazole antacid complex immediate-release (OACIR) and omeprazole delayed-release (OME-DR) on omeprazole pharmacokinetics and gastric pH in healthy subjects [abstract]. Gastroenterology 2003, 124:A228.CrossRefGoogle Scholar
  23. 23.
    Conrad SA, Gabrielli A, Margolis B, et al.: Randomized, double-blind comparison of immediate-release omeprazole oral suspension versus intravenous cimetidine for the prevention of upper gastrointestinal bleeding in critically ill patients. Crit Care Med 2005, 33:760–765.PubMedCrossRefGoogle Scholar
  24. 24.
    Macdougall BRD, Bailey RJ, Williams R: H2-receptor antagonists and antacids in the prevention of acute gastrointestinal hemorrhage in fulminant hepatic failure: two controlled trials. Lancet 1977, 19:617–619.CrossRefGoogle Scholar
  25. 25.
    Baghaie AA, Mojtahedzadeh M, Levine RL, et al.: Comparison of the effect of intermittent administration and continuous infusion of famotidine on gastric pH in critically ill patients: Results of a prospective randomized, crossover study. Crit Care Med 1995, 23:687–691.PubMedCrossRefGoogle Scholar
  26. 26.
    Pemberton LB, Schaefer N, Goehring L, et al.: Oral ranitidine as prophylaxis for gastric stress ulcers in intensive care unit patients: serum concentrations and cost comparisons. Crit Care Med 1993, 21:339–342.PubMedCrossRefGoogle Scholar
  27. 27.
    Driks MR, Craven DE, Celli BR, et al.: Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers. N Engl J Med 1987, 317:1376–1382.PubMedCrossRefGoogle Scholar
  28. 28.
    Shuman RB, Schuster DP, Zuckerman GR: Prophylactic therapy for stress ulcer bleeding: a reappraisal. Ann Intern Med 1987, 106:562–567.PubMedGoogle Scholar
  29. 29.
    Martin LF, Booth FVM, Reines D, et al.: Stress ulcers and organ failure in intubated patients in surgical intensive care units. Ann Surg 1992, 215:332–337.PubMedCrossRefGoogle Scholar
  30. 30.
    Van Essen HA, Van Blankenstein M, Wilson JH, et al.: Intragastric prostaglandin E2 and the prevention of gastrointestinal hemorrhage in ICU patients. Crit Care Med 1985, 13:957–960.PubMedCrossRefGoogle Scholar
  31. 31.
    Prod’hom G, Leuenberger P, Koerfer J, et al.: Nosocomial pneumonia in mechanically ventilated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer: a randomized controlled trial. Ann Intern Med 1994, 120:653–662.PubMedGoogle Scholar
  32. 32.
    Chamberlain CE: Acute hemorrhagic gastritis. Gastroenterol Clin North Am 1993, 22:843–873.PubMedGoogle Scholar
  33. 33.
    Shahmir M, Schuman BM: Complications of fiberoptic endoscopy. Gastrointest Endosc 1980, 26:86–91.PubMedGoogle Scholar
  34. 34.
    Matolo NM, Link DP: Selective embolization for control of gastrointestinal hemorrhage. Am J Surg 1979, 138:840–844.PubMedCrossRefGoogle Scholar
  35. 35.
    Goldman ML, Land WC, Bradley EL, Anderson RT: Transcatheter therapeutic embolization in the management of massive upper gastrointestinal bleeding. Radiology 1976, 120:513–521.PubMedGoogle Scholar
  36. 36.
    Akbulut KG, Gonul B, Turkyilmaz A, et al.: The role of epidermal growth factor formulation on stress ulcer healing of the gastric mucosa. Surg Today 2002, 32:880–883.PubMedCrossRefGoogle Scholar
  37. 37.
    Michida T, Kawano S, Masuda E, et al.: Endothelin-1 in the gastric mucosa in stress ulcers of critically ill patients. Am J Gastroenterol 1997, 92:1177–1181.PubMedGoogle Scholar
  38. 38.
    Choo D, Khwaja K, Nori K, et al.: In vivo characterization of the molecular-genetic changes in gastric mucosa during the development of acute gastritis and stress ulceration. J Trauma 2002, 52:720–726.PubMedCrossRefGoogle Scholar
  39. 39.
    Mutlu GM, Mutlu EA, Factor P: GI complications in patients receiving mechanical ventilation. Chest 2001, 119:1222–1241.PubMedCrossRefGoogle Scholar
  40. 40.
    SilenW: The prevention and management of stress ulcers. Hosp Pract 1980, 15:93–100.PubMedGoogle Scholar

Copyright information

© Current Science Inc 2006

Authors and Affiliations

  • Richard F. Harty
    • 1
  • Hari B. Ancha
  1. 1.Section of Gastroenterology, Department of MedicineOklahoma University Medical CenterOklahoma CityUSA

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