In critically ill patients, stress ulcerations usually occur in the fundus and body of the stomach, but sometimes develop in the antrum, duodenum, or distal esophagus. They tend to be shallow and cause oozing of blood from superficial capillary beds. Deeper lesions may also occur, which can erode into the submucosa and cause massive hemorrhage, perforation, or both.
●In critically ill patients, histamine-2 receptor antagonists (H2 blockers), proton pump inhibitors (PPIs), and antacids reduce overt gastrointestinal (GI) bleeding when compared to placebo or no prophylaxis.
●For critically ill patients who have risk factors for stress ulceration, we recommend prophylaxis with agents that suppress gastric acid (eg, PPI, H2 blockers, antacid) rather than no prophylaxis (Grade 1B). Risk factors include the following: mechanical ventilation for more than 48 hours, coagulopathy, GI ulceration or bleeding within the past year, traumatic brain injury, traumatic spinal cord injury, severe burns >35 percent of the body surface area, or two or more minor risk factors.
●For critically ill patients without any of the above risk factors, stress ulcer prophylaxis should be considered on a case-by-case basis. Considerations include whether the patient is receiving enteral nutrition, how long the patient is expected to be without enteral nutrition, the severity of the patient’s illness, and the patient’s comorbidities.
●For critically ill patients who are able to receive enteral medications and in whom stress ulcer prophylaxis is indicated, we suggest an oral PPI rather than an alternative prophylactic agent (Grade 2B).
●For critically ill patients who cannot receive enteral medications and in whom stress ulcer prophylaxis is indicated, we suggest an intravenous H2 blocker or an intravenous proton pump inhibitor (Grade 2B). Intravenous H2 blockers may be particularly preferred in those for whom cost is an issue.
●In critically ill patients, H2 blockers, PPIs, and antacids reduce the frequency of overt GI bleeding in critically ill patients compared to placebo or no prophylaxis. PPIs may be more effective at reducing the rate of GI bleeding but trials comparing individual agents are limited by methodologic flaws.
●Prophylactic agents that increase gastric pH (PPI, H2 blockers, antacids) may increase the frequency of nosocomial pneumonia, compared to prophylactic agents that do not alter gastric pH (sucralfate). PPIs and H2 blockers may also be associated with an increased risk of clostridium difficile infection. This risk should not preclude the administration of GI prophylaxis to critically ill patients, when it is indicated.