From the Guidelines
Enteral diet is less effective for the immediate prevention of stress gastritis compared to sucralfate, proton pump inhibitors (PPIs), and histamine-2 (H2) receptor antagonists. When considering the prevention of stress-related gastrointestinal bleeding in critically ill adults, the most recent and highest quality studies suggest that while enteral nutrition has some benefits, it does not provide the immediate and direct protection against gastric acid that medications like PPIs, H2 receptor antagonists, and sucralfate offer 1.
Key Points to Consider:
- PPIs and H2 receptor antagonists are recommended as first-line agents for stress ulcer prophylaxis in critically ill adults with risk factors for clinically important stress-related upper gastrointestinal bleeding (UGIB) 1.
- Sucralfate is also effective but has a different mechanism of action, forming a protective barrier over damaged mucosa.
- Enteral nutrition, although beneficial for overall gut health, does not directly neutralize gastric acid or provide immediate mucosal protection like pharmacological interventions.
- The choice between PPIs and H2 receptor antagonists may depend on factors such as the severity of illness and the presence of specific risk factors, with PPIs being associated with reduced clinically important UGIB but possibly increased mortality compared to H2RAs 1.
Recommendations for Practice:
- For immediate prevention of stress gastritis in high-risk patients, initiate a PPI or H2 blocker promptly.
- Consider transitioning to enteral nutrition as soon as feasible to support overall gut health.
- Maintain pharmacological prophylaxis until risk factors for stress-related UGIB resolve, based on guidelines that suggest discontinuing prophylaxis when critical illness is no longer evident or the risk factor(s) is no longer present 1.
From the Research
Efficacy of Options in Preventing Stress Gastritis
- The options provided for preventing stress gastritis include sucralfate, proton pump inhibitors (PPIs), enteral diet, and histamine-2 (H2) receptor antagonists.
- According to the studies 2, 3, 4, 5, 6, PPIs and H2RAs have been shown to be effective in reducing the risk of clinically important gastrointestinal bleeding.
- Enteral diet has also been associated with a decreased risk of clinically important GI bleeding, particularly in patients who receive enteral nutrition 5.
- However, sucralfate is not recommended for stress ulcer prophylaxis, as stated in the guideline 2, which suggests using a PPI rather than a H2RA and recommends against using sucralfate.
Comparison of Options
- PPIs have been shown to be more effective than H2RAs in reducing the risk of clinically significant GI bleeding 4.
- Enteral diet may have benefits in reducing the risk of GI bleeding, but the evidence is not as strong as for PPIs and H2RAs 5.
- Sucralfate is not recommended due to its lower efficacy compared to PPIs and H2RAs 2.
Less Effective Option
- Based on the evidence, sucralfate is the less effective option for immediate prevention of stress gastritis, as it is not recommended by the guideline 2 and has been shown to be less effective than PPIs and H2RAs in reducing the risk of GI bleeding.