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Bleeding in the Upper Part of the Gastrointestinal Tract Due to Stress Ulcers

Corresponding author: Richard W. Carlson, MD, PhD, Department of Medicine, Maricopa Medical Center, 2601 East Roosevelt, Phoenix, AZ 85008.

Critically ill patients are at increased risk for bleeding in the upper part of the gastrointestinal tract (UGIB) from stress ulcers. Risk factors for the development of bleeding include mechanical ventilation for more than 48 hours and coagulopathy.^1,2 Mechanisms that lead to bleeding are often multi-factorial but include splanchnic vasoconstriction and hypoperfusion with altered mucosal blood flow, acid back-diffusion with reduction of bicarbonate secretion, and changes in gastrointestinal motility.^3,4 The rate of clinically significant bleeding is low, although when such bleeding occurs, it is associated with prolonged stay in the intensive care unit, increased costs, and mortality.⁵

A variety of agents have been used to prevent stress ulcers, including antacids, barrier protection agents, histamine₂ receptor antagonists (H₂RAs), and proton pump inhibitors (PPIs). The effectiveness and complications of these various mechanisms of prophylaxis have been examined in numerous studies. Surveys of critical care physicians indicate that although stress-related UGIB is relatively uncommon, prophylaxis is necessary and H₂RAs are generally used in most instances⁶; however, PPIs, despite their greater costs, are becoming more widely used.

In this issue of the American Journal of Critical Care, Ojiako et al⁷ review and compare the use and effectiveness of pantoprazole (a PPI) and famotidine (an H₂RA) on UGIB in critically ill patients receiving mechanical ventilation in a medical-surgical intensive care unit of a university hospital. Patient groups were similar with respect to clinical parameters, although scores on the Acute Physiology and Chronic Health Evaluation II differed somewhat between the groups. The group treated with the H₂RA was markedly larger (n=522) than the group that received the PPI (n=95), reflecting the practice of the unit. Nevertheless, bleeding occurred more commonly in the group treated with the PPI (P = .03), and patients treated with the PPI who were receiving hemodialysis experienced more bleeding than did dialysis patients who received the H₂RA. The overall number of patients who had bleeding in each group, however, was small.

The study by Ojiako et al⁷ highlights and expands on our knowledge of this subject. First, UGIB due to stress ulcers is relatively uncommon, and patients with increased risk can be identified. Second, in this and other studies, H₂RAs appear to be cost-effective and clinically effective, although issues of thrombocytopenia and changes in mental status may be considerations in some patients. Finally, both PPIs and H₂RAs may increase the risk of ventilator-associated pneumonia, although Ojiako and colleagues found no significant difference in the frequency of this complication, and this issue remains controversial.

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REFERENCES

1. Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med. 1994;330(6):377–381.[Abstract/Free Full Text]
2. Steinberg KP. Stress-related mucosal disease in the critically ill patient: risk factors and strategies to prevent stress-related bleeding in the intensive care unit. Crit Care Med. 2002;30 (6 suppl):S362–S364.[Medline]
3. Mutlu GM, Mutlu EA, Factor P. GI complications in patients receiving mechanical ventilation. Chest. 2001;119(4):1222–1241.[Medline]
4. Silen W. The prevention and management of stress ulcers. Hosp Pract. 1980;15(3):93–100.[Medline]
5. Cook DJ, Griffith LE, Walter SD, et al. The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients. Crit Care. 2001;5(6):368–375.[Medline]
6. Daley RJ, Rebuck JA, Welage LS, Rogers FB. Prevention of stress ulceration: current trends in critical care. Crit Care Med. 2004;32(10):2008–2013.[Medline]
7. Ojiako K, Shingala H, Schorr C, Gerber DR. Comparison of famotidine and pantoprazole for preventing bleeding in the upper gastrointestinal tract of critically ill patients receiving mechanical ventilation. Am J Crit Care. 2008;17(2):142–147.[Abstract/Free Full Text]

This Article Full Text (PDF) Respond to This Article Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Carlson, R. W. Articles by Andhavarapu, S. Search for Related Content PubMed PubMed Citation Articles by Carlson, R. W. Articles by Andhavarapu, S.