stress ulceration

Introduction

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 (4% vs 0.1% without risk factors) thus overall risk is low; respiratory failure requiring mechanical ventilation for > 2 days

Pathology

• gastric acid is critical component
• hypersecretion of acid is uncommon except in patients with head injury
• gastric mucosal blood flow is altered
• disruption of gastric mucosa with erosions, ulceration & hemorrhage
• shallow ulcerations in the gastric fundus are ubiquitous in critically ill patients

Management

• prophylaxis:
• indications
  • prolonged mechanical ventilation
  • coagulopathy
• pharmaceutical agents
  • H2-receptor antagonists
    • effective for prophylaxis of stress ulceration
    • but may increase risk of pneumonia
  • sucralfate
    • may reduce risk of pneumonia & death
  • antacids
• no therapy has proven efficacy in decreasing mortality

More general terms

• gastric ulcer