Stress Ulceration Key Points & References

      
       

 

          
       

  1. Stress ulceration is a gastrointestinal mucosal injury related to critical illness.

  2. There is a relationship between GI bleeding and severity of disease.

  3. Likewise there is a strong relationship between bleeding and mortality.

  4. Ulceration is caused by ischemic injury to the gastric mucosa, loss of cytoprotectants and assault by gastric acid.

  5. The major risk factors are respiratory failure, coagulopathy, sepsis, hypotension and hepatic and renal failure.

  6. The incidence of stress ulceration is diminishing, probably reflecting better care before and during intensive care admission.

  7. Ranitidine and sucralfate are the most effective agents. Ranitidine is associated with a lower incidence of clinically significant bleeding, sucralfate with a lower incidence of pneumonia.

  8. Nosocomial pneumonia is the main complication of ulcer prophylaxis treatment.

  9. Patients who do not have one of the six major risk factors do not require treatment.

References
 

   (1)    Pruitt BA, Jr., Foley FD, Moncrief JA. Curling's ulcer: a clinical-pathology study of 323 cases. Ann Surg 1970; 172(4):523-539.

   (2)    Cook DJ, Fuller HD, Guyatt GH, Marshall JC, Leasa D, Hall R et al. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med 1994; 330(6):377-381.

   (3)    Skillman JJ, Bushnell LS, Goldman H, Silen W. Respiratory failure, hypotension, sepsis, and jaundice. A clinical syndrome associated with lethal hemorrhage from acute stress ulceration of the stomach. Am J Surg 1969; 117(4):523-530.

   (4)    Cook D, Guyatt G, Marshall J, Leasa D, Fuller H, Hall R 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; 338(12):791-797.

   (5)    Schuster DP, Rowley H, Feinstein S, McGue MK, Zuckerman GR. Prospective evaluation of the risk of upper gastrointestinal bleeding after admission to a medical intensive care unit. Am J Med 1984; 76(4):623-630.

   (6)    Shuman RB, Schuster DP, Zuckerman GR. Prophylactic therapy for stress ulcer bleeding: a reappraisal. Ann Intern Med 1987; 106(4):562-567.

   (7)    Rosen HR, Vlahakes GJ, Rattner DW. Fulminant peptic ulcer disease in cardiac surgical patients: pathogenesis, prevention, and management. Crit Care Med 1992; 20(3):354-359.

   (8)    Wijdicks EF, Fulgham JR, Batts KP. Gastrointestinal bleeding in stroke. Stroke 1994; 25(11):2146-2148.

   (9)    Messori A, Trippoli S, Vaiani M, Gorini M, Corrado A. Bleeding and pneumonia in intensive care patients given ranitidine and sucralfate for prevention of stress ulcer: meta-analysis of randomised controlled trials. BMJ 2000; 321(7269):1103-1106.

(10)    Cook DJ, Walter SD, Cook RJ, Griffith LE, Guyatt GH, Leasa D et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med 1998; 129(6):433-440.

(11)    Heiselman DE, Hulisz DT, Fricker R, Bredle DL, Black LD. Randomized comparison of gastric pH control with intermittent and continuous intravenous infusion of famotidine in ICU patients. Am J Gastroenterol 1995; 90(2):277-279.

          
                   
       

         
     

       
       

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