Prevention and treatment of stress ulcers in critically ill patients

Critically ill patients are at increased risk of developing stress-related mucosal lesions. The pathogenesis of stress-related mucosal disease is not entirely clear, but probably is associated with impairment of mucosal protective mechanisms due to compromised gastric mucosal microcirculation. Acid also plays an integral role. The incidence of gastrointestinal bleeding among intensive care unit patients has been declining over the past 30 years. Only a small proportion of patients with stress-related mucosal lesions develop clinically overt bleeding, and the majority of the overt bleedings do not lead to hemodynamic instability. However, the presence of gastrointestinal bleeding in a critically ill patient predicts markedly increased mortality. Prolonged mechanical ventilation and coagulopathy are the most important predictors of stress ulcer related bleeding. Critically ill patients with stress ulcer related bleeding should be managed in the acute setting just as patients presenting with upper gastrointestinal bleeding. Available evidence supports the use of stress ulcer prophylaxis in patients with risk factors for bleeding. Both histamine 2 receptor antagonists and sucralfate are effective forms of stress ulcer bleeding prophylaxis. More potent acid suppression by proton pump inhibitors may offer additional benefit in the prevention of stress ulcer bleeding.