What is the treatment for septic gastropathy?

Treatment of Septic Gastropathy

Patients with sepsis or septic shock who have risk factors for gastrointestinal bleeding should receive stress ulcer prophylaxis with either proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs), while those without risk factors should not receive prophylaxis. 1

Risk Stratification for Stress Ulcer Prophylaxis

The decision to initiate prophylaxis hinges on identifying specific risk factors for GI bleeding:

• Mechanical ventilation for ≥48 hours (odds ratio 15.6) 1
• Coagulopathy (odds ratio 4.3) 1
• Septic shock requiring vasopressors 1
• Hypotension 1

Patients with respiratory failure and coagulopathy have a 3.7% risk of clinically important GI bleeding, requiring treatment of 27 patients to prevent one bleeding event. 1 In contrast, patients without these risk factors have only a 0.1% bleeding risk, making prophylaxis unnecessary and potentially harmful. 1

Pharmacological Management

First-Line Acid Suppression Therapy

For patients meeting criteria for prophylaxis, either PPIs or H2RAs are acceptable options, though PPIs may offer superior protection against GI bleeding. 1

• PPI dosing: Standard dose once daily (e.g., pantoprazole 40 mg, omeprazole 20 mg) 1
• H2RA dosing: Standard institutional protocols 1
• The 2012 guidelines suggested preferring PPIs over H2RAs, but the 2016 update weakened this to equipoise between the two agents 1

Duration of Therapy

• Continue prophylaxis only while risk factors persist 1
• Discontinue when mechanical ventilation is discontinued and coagulopathy resolves 1
• Do not continue prophylaxis beyond the ICU stay in patients without ongoing risk factors 1

Nutritional Support Strategy

Early enteral nutrition should be initiated rather than complete fasting or IV glucose alone, as this supports gut mucosal integrity and may reduce stress ulcer risk. 1

• Start enteral feeding within 48 hours of sepsis diagnosis 1
• Begin with early trophic/hypocaloric feeding and advance according to tolerance 1
• Avoid parenteral nutrition alone in the first 7 days if enteral feeding is feasible 1
• Do not routinely monitor gastric residual volumes unless feeding intolerance develops 1

Management of Feeding Intolerance

If gastric residual volumes exceed 500 mL per 6 hours: 1

• First-line: Intravenous erythromycin 100-250 mg three times daily for 24-48 hours 1
• Alternative: Intravenous metoclopramide 10 mg two to three times daily 1
• Prokinetic effectiveness decreases to one-third after 72 hours; discontinue after 3 days 1
• Consider post-pyloric feeding if large residuals persist despite prokinetics 1

Common Pitfalls and Caveats

Critical errors to avoid:

• Do not provide prophylaxis to patients without risk factors - this exposes them to unnecessary medication risks including Clostridium difficile infection, pneumonia, and nutrient malabsorption without benefit 1, 2
• Do not continue prophylaxis indefinitely - reassess daily and discontinue when risk factors resolve 1
• PPIs can interfere with absorption of other medications including antiretrovirals, warfarin (increased effect), and digoxin (increased toxicity), requiring dose adjustments 2
• Long-term PPI use risks include vitamin B12, calcium, iron, and magnesium deficiencies; osteoporotic fractures; and interstitial nephritis 2
• The balance of benefits versus harms may shift based on local epidemiology of ventilator-associated pneumonia and C. difficile infections 1

Special Considerations

• In patients receiving enteral nutrition, the protective benefit of acid suppression may be reduced, though prophylaxis guidelines remain unchanged 1
• Sucralfate is not recommended over acid suppression therapy based on comparative effectiveness data 1
• Combination pharmacologic VTE prophylaxis with LMWH and mechanical prophylaxis should be provided concurrently when not contraindicated 1