Stress ulcers

Stress ulcers, stress-related mucosal disease (SRMD), are acute gastric mucosal lesions that develop in response to severe physiological stress.
These ulcers are typically found in critically ill patients: those in intensive care units (ICUs), and are associated with conditions such as shock, sepsis, trauma, and major surgery.
Contributing factors include mucosal ischemia due to hypotension and shock, increased gastric acid secretion, and a breakdown of the mucosal barrier.
Luminal acid and ischemia are necessary for the production of stress ulcers, and disruption of the gastric mucosal barrier by refluxed duodenal content may also contribute.
Clinically, stress ulcers often present with gastrointestinal bleeding.
Unlike peptic ulcers, stress ulcers are usually asymptomatic until bleeding occurs.
Endoscopy is the primary diagnostic tool for identifying stress ulcers.

Critically ill patients are at risk for stress induced G.I. ulceration, which may cause upper gastrointestinal bleeding.

The treatment for stress ulcers primarily involves prophylaxis, which is the prevention of clinically important stress-related mucosal bleeding from the upper gastrointestinal tract.

The prophylaxis regimens available for critically ill patients include proton pump inhibitors (PPIs) and histamine 2 receptor antagonists (H2RAs).

Sucralfate and antacids are also used to strengthen mucosal defenses.

The evidence does not clearly support lower bleeding rates with PPIs over H2RAs when evaluating only the trials at low risk for bias.

PPIs appear to be the dominant drug class used worldwide today.

Guidelines suggest stress ulcer prophylaxis in adult patients who have risk factors for gastrointestinal bleeding.

The use of stress ulcer prophylaxis may be associated with an increased risk of hospital-acquired pneumonia or Clostridium difficile infection.

Proton pump inhibitors slightly, but significantly decrease the risk of important gastrointestinal bleeding and have a decent chance of slightly decreasing mortality, in less severely ill patients with mechanical ventilation.

Certain proton pump inhibitors do not decrease, and may slightly increase mortality in severely ill patients.

Among patients undergoing invasive, ventilation, pantoprazole (proton pump inhibitor) results in significant lower risk of clinically, important upper gastrointestinal bleeding, than placebo with no significant effect on mortality (REVISE investigators).


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