Which of the following does not have a direct efficacy in preventing stress gastritis: Sucralfate, Proton pump inhibitors (PPIs), Enteral diet, or Histamine-2 (H2) receptor antagonists?

Efficacy of Agents in Preventing Stress Gastritis

Enteral diet does not have direct efficacy in preventing stress gastritis, although it provides some protective effects. 1

Pharmacological Agents with Proven Efficacy

Proton Pump Inhibitors (PPIs)

• PPIs are effective in preventing stress gastritis by potently suppressing gastric acid secretion
• Recommended by the Society of Critical Care Medicine as a primary option for stress ulcer prophylaxis in high-risk critically ill patients 1
• They achieve a more rapid and sustained increase in gastric pH compared to other agents 2

Histamine-2 Receptor Antagonists (H2RAs)

• H2RAs have well-established efficacy in preventing stress ulcer bleeding in critically ill patients
• The Society of Critical Care Medicine guidelines confirm that H2RAs significantly reduce the risk of clinically important GI bleeding compared to placebo 1
• However, they are associated with rapid tachyphylaxis (diminishing effect over time) 2

Sucralfate

• Has direct protective effects on the gastric mucosa
• Shown to be significantly more effective than H2-antagonists with a typical odds ratio of 0.532 1, 3
• May provide additional protection when used with PPIs or H2RAs 1
• Works by forming a protective barrier over the gastric mucosa rather than by acid suppression 4

Enteral Nutrition and Stress Ulcer Prophylaxis

• Enteral nutrition provides some protection against stress-related GI bleeding by:
  • Maintaining mucosal blood flow
  • Buffering gastric acid
  • Providing nutrients to support mucosal integrity 1
• However, this protection is indirect and insufficient on its own
• Patients with risk factors still benefit from pharmacological stress ulcer prophylaxis even when enterally fed 1
• Unlike the other three options (PPIs, H2RAs, and sucralfate), enteral nutrition is not considered a direct pharmacological prophylactic agent for stress gastritis

Risk Factors Requiring Pharmacological Prophylaxis

Patients with the following risk factors should receive pharmacological prophylaxis with either PPI or H2RA, regardless of enteral feeding status:

• Shock (particularly in patients on vasopressors)
• Coagulopathy
• Chronic liver disease
• Sepsis 1

Comparative Efficacy and Considerations

• Recent cohort studies suggest that H2RAs might actually be associated with lower risks of GI bleeding compared to PPIs (OR = 1.98,95% CI = 1.30-3.01) 5
• Sucralfate has been shown to be more effective than H2-antagonists and equally effective as antacids in preventing macroscopically visible stress bleeding 3
• Sucralfate may be associated with lower rates of nosocomial pneumonia compared to both H2RAs and antacids 3

Clinical Approach to Stress Ulcer Prophylaxis

1. Assess patient for risk factors (shock, coagulopathy, chronic liver disease, sepsis)
2. If risk factors present, initiate pharmacological prophylaxis with either PPI or H2RA
3. Consider adding sucralfate for additional protection
4. Initiate enteral nutrition when feasible as a supportive measure, not as primary prophylaxis
5. Discontinue pharmacological prophylaxis when risk factors resolve or critical illness is no longer evident 1