Describe stress ulcers.
Stress ulcers are ulcers associated with erosive gastritis, i.e., acute damage to the gastric mucosa resulting from increased levels of endogenous glucocorticoids and decreased blood flow to the stomach.
Describe the etiology.
Critical illness, such as:
Respiratory failure requiring ventilation for > 48 hours,
Severe head or spinal cord injury
Burns affecting a surface area > 35% of the body surface area.
Describe the types.
Curling ulcer: severe burns → decreased plasma volume → decreased gastric blood flow → hypoxic tissue injury of stomach surface epithelium → weakening of the normal mucosal barrier
Cushing ulcer: brain injury → increased vagal stimulation → increased production of stomach acid via acetylcholine release
Describe stress ulcer prophylaxis.
Stress ulcer prophylaxis should be considered in any critically ill patient with a risk of GI bleeding. Prophylaxis was formerly recommended for all ICU patients, but evidence suggests that risks (e.g., for pneumonia) outweigh the benefits in patients with low bleeding risk.
List prophylactic agents.
PPIs (preferred for patients with moderate-to-high risk factors): e.g., pantoprazole
H2 receptor blockers (may be used as an alternative): e.g., famotidine
Continue stress ulcer prophylaxis for as long as significant risk factors are present or until critical illness resolves.
Both PPIs and H2 receptor antagonists may increase the risk of pneumonia in critically ill patients.
Stress ulcer prophylaxis likely has little effect on mortality, length of admission, length of stay in critical care units, and duration of mechanical ventilation.