How does mechanical ventilation increase the risk of peptic ulcer disease (PUD)?

From the Guidelines

Mechanical ventilation alone is not a firm risk factor for increasing peptic ulcer disease, as indicated by the latest guidelines from the Society of Critical Care Medicine and American Society of Health-System Pharmacists 1. When considering the relationship between mechanical ventilation and peptic ulcer disease, it's essential to understand the factors that truly increase the risk of stress-related gastrointestinal bleeding in critically ill adults. According to the most recent study published in Critical Care Medicine in 2024 1, factors such as coagulopathy, shock, and chronic liver disease are likely to increase this risk.

Key Factors Influencing Peptic Ulcer Disease Risk

• Coagulopathy
• Shock
• Chronic liver disease These factors, rather than mechanical ventilation itself, play a significant role in the development of peptic ulcer disease in critically ill patients. However, it's also important to note that critically ill patients, including those on mechanical ventilation, often experience increased physiological stress, which can stimulate gastric acid secretion and reduce protective mucosal barriers in the stomach and duodenum.

Prevention Strategies

To prevent stress-related gastrointestinal bleeding, including peptic ulcer disease, in critically ill adults, especially those with risk factors, the guidelines recommend the use of either proton pump inhibitors or histamine-2 receptor antagonists at low dosage regimens 1. Additionally, enteral nutrition is likely to reduce the risk of ulcer bleeding, as it helps maintain mucosal integrity. Prophylaxis should be tailored based on the individual patient's risk factors and discontinued when the critical illness is no longer evident or the risk factor(s) is no longer present 1.

From the Research

Mechanical Ventilation and Peptic Ulcer Disease

• Mechanical ventilation can increase the risk of peptic ulcer disease due to various factors, including stress, immobilization, and the use of certain medications 2, 3, 4, 5, 6.
• Studies have shown that critically ill patients on mechanical ventilation are at a higher risk of developing stress-related gastrointestinal hemorrhage, particularly those with coagulopathy or requiring mechanical ventilation for more than 48 hours 2, 4.
• The use of proton pump inhibitors, such as pantoprazole, has been shown to reduce the risk of clinically important upper gastrointestinal bleeding in patients undergoing invasive ventilation 5.
• However, the use of certain medications, such as histamine-2 receptor antagonists, may increase the risk of ventilator-associated pneumonia, which can offset the benefits of stress ulcer prophylaxis 3, 4.
• The decision to use stress ulcer prophylaxis in patients on mechanical ventilation should be based on individual patient factors, including the risk of gastrointestinal bleeding and the risk of pneumonia 3, 4.

Risk Factors for Peptic Ulcer Disease in Mechanically Ventilated Patients

• Coagulopathy
• Prolonged mechanical ventilation (> 48 hours)
• Use of certain medications (e.g. histamine-2 receptor antagonists)
• Immobilization
• Stress

Prevention and Management of Peptic Ulcer Disease in Mechanically Ventilated Patients

• Use of proton pump inhibitors (e.g. pantoprazole) to reduce the risk of clinically important upper gastrointestinal bleeding 5
• Use of sucralfate to reduce the risk of stress-related gastrointestinal hemorrhage 2
• Monitoring for signs of gastrointestinal bleeding and pneumonia
• Individualized decision-making based on patient factors and risk assessment 3, 4