Stress ulcer prophylaxis

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 STRESS-RELATED MUCOSAL DISEASE (SRMD) / STRESS ULCERS

 I. DEFINITIONS

1. Stress-Related Mucosal Disease (SRMD)

  • Acute erosive and ulcerative gastritis occurring in critically ill patients.
  • Includes:
    • Stress erosions (superficial)
    • Stress ulcers (deep, bleeding lesions)

2. Stress Ulcers

  • Multiple shallow mucosal lesions in the gastric fundus and body, caused by hypoperfusion and acid-mediated injury.

 II. PATHOPHYSIOLOGY

1. Gastric Mucosal Barrier Breakdown

  • Stress → splanchnic vasoconstriction → mucosal ischemia
  • Ischemia → ↓ bicarbonate/mucus, ↑ H⁺ back-diffusion → mucosal necrosis

2. Key Factors

Pathogenic Mechanism

Details

Ischemia

Hypoperfusion due to shock, sepsis, hypovolemia

Acid & Pepsin

Contribute to mucosal damage

Cytokines

TNF-α, IL-1 → impair mucosal integrity

Oxidative Stress

ROS during reperfusion injury

Bile Reflux

Disrupts epithelial tight junctions

 III. RISK FACTORS

 Major Independent Risk Factors 

  • Mechanical ventilation ≥ 48 hours(controversial)
  • Coagulopathy:
    • Platelets <50,000/mm³
    • INR >1.5 or aPTT >2× control

 Additional Risk Factors (Supportive):

  • Sepsis
  • ICU stay > 7 days
  • High-dose corticosteroids (>250 mg hydrocortisone/day)
  • Traumatic brain injury, spinal cord injury
  • Major burns (>35% BSA) – Curling’s ulcer
  • Multiple organ dysfunction syndrome (MODS)
  • Acute renal or hepatic failure
  • History of GI ulcer or bleeding within 1 year

 IV. CLINICAL FEATURES

1. Usually Asymptomatic

  • Most cases are subclinical erosions

2. Overt Upper GI Bleeding

  • Hematemesis, coffee-ground emesis
  • Melena
  • Anemia
  • Hemodynamic instability (if severe bleeding)

 V. DIAGNOSIS

A. Clinical Suspicion

  • In ICU patients with risk factors and unexplained blood loss

B. Endoscopy

  • EGD = gold standard
  • Findings:
    • Diffuse superficial erosions
    • Gastric body/fundus > duodenum
    • Rarely, visible vessels or active bleeding

C. Other Clues

  • Drop in hemoglobin
  • Positive nasogastric aspirate for blood
  • Occult blood in stool

 VI. DIFFERENTIAL DIAGNOSIS

  • Peptic ulcer disease
  • Mallory–Weiss tear
  • Esophageal varices
  • Dieulafoy lesion
  • Gastric antral vascular ectasia (GAVE)

 VII. INDICATION

1. Coagulopathy

Highest quality evidence.

Examples

  • Platelets <50,000/mm³
  • INR >1.5
  • aPTT >2× normal
  • Therapeutic anticoagulation with additional bleeding risk

Conditional recommendation. 

2. Shock

  • Includes Septic shock/Cardiogenic shock/Hemorrhagic shock/Obstructive shock
  • Especially if requiring vasopressors.
  • Conditional recommendation. 

3. Chronic liver disease

  • Cirrhosis
  • Portal hypertension
  • Significant hepatic dysfunction

Higher baseline bleeding risk.

Conditional recommendation. 

4. Neurocritical illness

Evidence is weaker.

Examples

  • Severe traumatic brain injury
  • Intracranial hemorrhage
  • Large ischemic stroke
  • Neurosurgery
  • Spinal cord injury

The panel suggests considering SUP individually rather than routinely.

Patients tolerating enteral feeding may derive less additional benefit from SUP, but enteral nutrition alone is not a reason to stop or withhold SUP if major bleeding risk factors are present.

 

NOT Indicated In:

  • General ward patients
  • ICU patients without risk factors
  • Patients tolerating enteral feeds & no risk factors

Overuse → harms > benefits.

Previous teaching

2024 SCCM/ASHP

Mechanical ventilation >48 h is a major indication

No longer considered an independent indication

PPIs preferred for everyone

Either PPI or H2RA acceptable

Enteral feeding does not matter

Enteral nutrition itself lowers bleeding risk

Continue SUP until hospital discharge

Stop once ICU risk factors resolve; discontinue before ICU transfer

Agents Used(SCCM/ASHP guidelines)

Class

Example

Mechanism

PPIs
  • Pantoprazole ,Esomeprazole,omeprazole 40 mg/day
  • Lansoprazole 30 mg/day(should be taken 30-60 minutes before a meal.)
  • Irreversible H⁺/K⁺ ATPase inhibitor
  • OD dosing in prophylaxis, B.D dosing in bleeding(infusion is unnecessary)

H₂ Blockers

Famotidine—20 mg B.D (adjust for renal function)

Reversible H₂ receptor blocker

Preferred Agent

  • PPI > H₂ Blocker 

Reasons

  • Compared with H2 blockers, PPIs  Lower clinically important UGIB slightly more.
  • No dose adjustment in renal failure
  • Less risk of delirium
  • PPIs do not cause C. difficile, pneumonia(SUP-ICU trial, REVISE trial)

BUT

  • No mortality benefit
  • No ICU LOS benefit
  • No reduction in ventilator duration

Discontinuation

Discontinue when

  • Shock has resolved
  • Coagulopathy corrected
  • Critical illness resolving
  • ICU risk factors no longer present

Do not continue routinely until hospital discharge.


References

2024 SCCM/ASHP Guideline for Stress Ulcer Prophylaxis (SUP)

Society of Critical Care Medicine (SCCM) & American Society of Health-System Pharmacists (ASHP)
Published: July 2024 (Crit Care Med 2024;52:e421–e430) 

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