Intramucosal pH: What, How, Whom, When and Where?

  • R. G. Fiddian-Green
Conference paper
Part of the Yearbook of Intensive Care and Emergency Medicine 1993 book series (YEARBOOK, volume 1993)


The indirect measurement of intramucosal pH (pHi) is derived from the carbon dioxide pressure (PCO2) in the lumen of the gut and the bicarbonate in arterial blood. This measurement was first conceived in 1981 [1] as a means of testing the hypothesis that a fall in pHi was the primary determinant of bleeding from stress ulceration. It was recognized shortly thereafter that pHi provided a metabolic measure of the adequacy of gut mucosal oxygenation [2] and that stress ulceration in patients was almost certainly a manifestation of ischemic mucosal injury [3]. It was discovered that during shock, endogenous vasoconstrictors act selectively on gut vasculature [4] and that ischemic mucosal injury might be a putative cause of multiple systems organ failure (MOF). The possibility that the measurement of pHi might be valuable in monitoring patients was not seriously considered until late 1986 [5, 6], and the possibility that it might be used to detect hemodynamically compensated shock and as an end- point in resuscitation from shock became apparent in late 1988 [7]. Ten years after the indirect measurement of pHi was devised, it was shown that including a normal pHi as a final endpoint in resuscitation could improve outcome in ICU patients [8].


Tissue Oxygenation Stress Ulceration Multiple System Organ Failure Splanchnic Ischemia Arterial Bicarbonate 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Fiddian-Green RG, Pittenger G, Whitehouse WM Jr (1982) Back diffusion of CO2 and its influence on the intramural pH in gastric mucosa. J Surg Res 33:39–44–8Google Scholar
  2. 2.
    Grum CM, Pittenger GL, Grant BJ, Fiddian-Green RG, Dantzker DR (1982) Noninvasive assessment of the adequacy of oxygenation at a peripheral tissue bed. Chest 82: 249 (Abstract)Google Scholar
  3. 3.
    Fiddian-Green RG, McGough E, Pittenger G, Rothman E (1983) Predictive value of intramural pH and other risk factors for massive bleeding from stress ulceration. Gastroenterology 85: 613–620PubMedGoogle Scholar
  4. 4.
    Porter JM, Sussman MS, Bulkley GB (1989) Splanchnic vasospasm in eireulatory shock. In: Marston A, Bulkley GB, Fiddian-Green RG, Haglund U (eds) Splanchnic ischemia and multiple organ failure. Edward Arnold, London, pp 73–88Google Scholar
  5. 5.
    Fiddian-Green RG (1988) Splanchnic ischemia and multiple organ failure in the critically ill. Ann Rev Coli Surg Engl 70: 128–134Google Scholar
  6. 6.
    Fiddian-Green RG (1989) Studies in splanchnic ischemia and multiple organ failure. In: Marston A, Bulkley GB, Fiddian-Green RG, Haglund U (eds) Splanchnic ischemia and multiple organ failure. Edward Arnold, London, pp 349–363Google Scholar
  7. 7.
    Haglund U, Fiddian-Green RG (1989) Assessment of adequatae tissue oxygenation in shock and critical illness: Oxygen transport in sepsis. Intensive Care Med 15: 475–477Google Scholar
  8. 8.
    Guttierez G, Palizas F, Doglio G, et al. (1992) Gastric intramucosal pH as a therapeutic index of tissue oxygenation in critically ill patients. Lancet 25: 195–199CrossRefGoogle Scholar
  9. 9.
    Fiddian-Green RG (1993) Tonometry: Theory and applications. Intensive Care World (In press)Google Scholar
  10. 10.
    Antonsson JB, Boyle CC, Kruithoff KL, et al. (1990) Validation of tonometric measurement of gut intramural pH during endotoxemia and mesenteric occlusion in pigs. Am J Physiol 259: G519–G523PubMedGoogle Scholar
  11. 11.
    Shijie S, Weil MH, Wanchun T, Gazmuri RJ, Noc M, Bisera J (1992) Gastric intramural bicar- bonate: Limitations of the tonometry method. Crit Care Med (Abst) 20: 566Google Scholar
  12. 12.
    Mosenthal AC, Wang H, Beilesle JM, et al. (1991) Mesenteric Lypoperfusion and decreased mucotal ATP in porcine endotoxicosis. Surg Forum:39–44-1Google Scholar
  13. 13.
    Schlichtig R (1991) In search of the dysoxic threshold. Intensive Care Med 17: 313–314PubMedCrossRefGoogle Scholar
  14. 14.
    Fiddian-Green RG, Stanley JC, Nostrant T, Phillips D (1989) Chronic gastric ischemia. A cause of abdominal pain or bleeding identified from the presence of gastric mucosal acidosis. J Car- diovasc Surg 30: 852–859Google Scholar
  15. 15.
    Landow L, Phillips DA, Heard SO, Prevost D, VanderSalm TJ, Fink MP (1991) Gastric tonometry and venous oximetry in cardiac surgery patients. Crit Care Med 19: 1226–1233PubMedCrossRefGoogle Scholar
  16. 16.
    Gutierrez G, Bismar H (1991) Distribution of blood flow in the critically ill patient. In: Wendt M, Lawin P (eds) Oxygen transport in the critically ill patient. Springer-Verlag, New York pp 127–135Google Scholar
  17. 17.
    Price K, Clark C, Gutierrez G (1992) Intravenous dobutamine improves gastric intramucosal pH in septic patients. Am Rev Resp Dis 145: A316 (Abstract)Google Scholar
  18. 18.
    Fiddian-Green RG, McGough E, Pittenger G, Rothman E (1983) Predictive value of intramural pH and other risk factors for massive bleeding from stress ulceration. Gastroentereology 85: 613–620Google Scholar
  19. 19.
    Fiddian-Green RG (1988) Assessment of the adequacy of mucosal oxygenation in patients with intraluminally located silicone tonometers. In: Manabe H, Zweifach BW, Messmer K (eds) Microcirculation in eireulatory disorders. Springer-Verlag Berlin, Heidelberg, pp 481–487CrossRefGoogle Scholar
  20. 20.
    Riddington D, Venkatesh B, Clutton-Brock T, Bion J (1993) Potential hazards in the estimation of gastric intramucosal pH. Lancet 340: 547CrossRefGoogle Scholar
  21. 21.
    Clausen JL, Murray KM (1985) Clinical applications of arterial blood gases: How much accura- cy do we need? J Med Technol 2: 19–21Google Scholar
  22. 22.
    Hansen JE, Jensen RL, Casburi R, Crapo RO (1989) Comparison of blood gas analyzer biases in measuring tonometered blood and a fluorocarbon-containing, proficiency-testing material. Am Rev Respir Dis 140: 403–409PubMedCrossRefGoogle Scholar
  23. 23.
    Heard SO, Helsmoortel CM, Kent JC, Shahnarian A, Fink MP (1991) Gastric tonometry in normal volunteers: Effect of ranitidine on calculated intramural pH. Crit Care Med 19: 271–274Google Scholar
  24. 24.
    Data on file, Tonometrics, Inc., Worcester, MAGoogle Scholar
  25. 25.
    Tonometrics, Inc. (1992) Tonometrics Technical Bulletins TB 9201 and TB 9202, Worcester, MAGoogle Scholar
  26. 26.
    Burnett RW, Covington AK, Maas AHJ, et al. (1989) IFFC Method (1988) for tonometry of blood: Reference materials for PCO2 and P02. J Clin Chem Clin Biochem 27: 404–408Google Scholar
  27. 27.
    Mythen MG, Roberts PC, Webb AR (1991) Gastric mucosal ischemia associated with major eomplications and death following routine major surgery. Proceedings of internationales Ste-glitzer Symposium, Berlin October 1991, p 85Google Scholar
  28. 28.
    Fiddian-Green RG, Baker S (1987) The predictive value of the stomach wall pH for complica- tions after cardiac Operations: Comparison with other monitoring. Crit Care Med 15: 153–156Google Scholar
  29. 29.
    Dowing HA, Beard CI, Cottam S, Potter DR (1992) Gastric mucosal pH predicts major morbi- dity following orthotopic liver transplantation. 5th Liver Intensive Care Group of Europe Meeting (Abstract)Google Scholar
  30. 30.
    Fiddian-Green RG, Baker S (1991) Nosocomial pneumonia in the critically ill: Product of aspi- ration or translocation. Crit Care Med 19: 763–769Google Scholar
  31. 31.
    Beale R, Bihari DJ (1993) Multiple organ failure: The pilgrim's progress. Crit Care Med 21: S1–S3PubMedCrossRefGoogle Scholar
  32. 32.
    Silverman HJ, Tuma P (1992) Gastric tonometry in patients with sepsis: Effects of dobutamine infusions and packed red blood cell transfusions. Chest 102: 184–188Google Scholar
  33. 33.
    Mythen MG, Hamilton-Davies C, Webb AR (1992) Gastric mucosal hypoperfusion associated with a poor outcome following major surgery: Cost implications. Association of Anaesthetists of Great Britain and Ireland, Bristol (Abstract)Google Scholar
  34. 34.
    Haglund U, Montgomery A, Borgstrom A (1990) Intraluminal pancreatic proteases and intestinal mucosal injury during ischemia and reperfusion. Circ Shock 31: 36–37 (Abstract)Google Scholar
  35. 35.
    Leon A, Raclot P, Cousson J, Lefort P, Suinat JL, Rendoing J (1991) Predictive value of gastric intramural pH in septic shock. Eur J Anaesthesiol (Abstract)Google Scholar
  36. 36.
    Gys T, Hubens A, Neels H, Lauwers LF, Peeter R (1988) The prognostic value of gastric intra-mural pH in surgical intensive care patients. Crit Care Med 16: 1222–1224PubMedCrossRefGoogle Scholar
  37. 37.
    Fiddian-Green RG, Haglund U, Guttierrez G, Shoemaker WC (1993) Goals for the resuscitation of shock. Crit Care Med (In press)Google Scholar
  38. 38.
    Diebel LN, Dulchavsky SA, Wilson RF (1992) Effect of increased intra-abdominal pressure on mesenteric arterial and intestinal mucosal blood flow. J Trauma 33: 45–49PubMedCrossRefGoogle Scholar
  39. 39.
    Truog RD (1992) Randomized controlled trials: Lessons from ECMO. Clin Res 40: 519–527PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 1993

Authors and Affiliations

  • R. G. Fiddian-Green

There are no affiliations available

Personalised recommendations