Stress ulcer prophylaxis in the intensive care unit
- Gerald L Weinhouse, MD
Gerald L Weinhouse, MD
- Assistant Professor of Medicine
- Harvard Medical School
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 or perforation .
The epidemiology, pathophysiology, risk factors, and prognosis of stress ulceration in the intensive care unit (ICU) are discussed in this topic review. In addition, stress ulcer prophylaxis is reviewed. Diagnosis and treatment of bleeding peptic ulcers are discussed separately. (See "Approach to acute upper gastrointestinal bleeding in adults" and "Overview of the treatment of bleeding peptic ulcers".)
Epidemiology — Estimates of the incidence of overt gastrointestinal (GI) bleeding range from 1.5 to 8.5 percent among all intensive care unit (ICU) patients, but may be as high as 15 percent among patients who do not receive stress ulcer prophylaxis [2-5]. Most episodes of overt GI bleeding in critically ill patients are due to gastric or esophageal ulceration, as determined by endoscopic studies [2,5]. Stress ulceration can also cause perforation. However, this complication is rare, occurring in fewer than 1 percent of surgical ICU patients .
Pathophysiology — Stress ulceration generally begins in the proximal regions of the stomach within hours of major trauma or serious illness. Endoscopy performed within 72 hours of a major burn or cranial trauma reveals acute mucosal abnormalities in greater than 75 percent of patients . Up to 50 percent of such lesions have endoscopic evidence of recent or ongoing bleeding, although only a small percentage of patients experience hemodynamic compromise due to acute blood loss .
Stress ulcerations that develop after the first several days of hospitalization tend to be deeper and more distal . In a study of 67 patients with GI bleeding that occurred an average of 14 days after admission, duodenal ulceration was the most common source of bleeding .
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