What is the best treatment approach for a patient with stress-induced gastropathy?

Treatment of Stress-Induced Gastropathy

All critically ill adults with coagulopathy, shock, or chronic liver disease should receive either proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) at low-dose regimens, combined with early enteral nutrition when feasible, to prevent clinically important upper gastrointestinal bleeding. 1

Risk Stratification: Who Needs Prophylaxis

High-risk patients requiring stress ulcer prophylaxis (SUP):

• Coagulopathy (absolute risk increase 4.8%, strongest predictor with OR = 4.3) 1, 2
• Shock of any etiology (absolute risk increase 2.6%) 1, 2
• Chronic liver disease (absolute risk increase 7.6%, highest bleeding risk) 1

Important caveat: Mechanical ventilation alone does NOT necessitate prophylaxis unless combined with one of the above risk factors. 1 This is a common pitfall—many clinicians reflexively start SUP for all ventilated patients, but the 2024 Society of Critical Care Medicine guidelines explicitly state there is no firm evidence for mechanical ventilation being an independent risk factor. 1

Low-risk patients: Do not use SUP in critically ill adults without the above risk factors, even if enterally fed. 1

Pharmacologic Treatment Algorithm

First-Line Medication Selection

Either PPIs or H2RAs are equally acceptable as first-line agents (conditional recommendation, moderate certainty). 1 However, the evidence shows PPIs reduce clinically important bleeding more effectively (RR 0.52; 95% CI, 0.30–0.81) without conclusive effects on mortality, pneumonia, or Clostridioides difficile infection. 1, 3

Dosing specifications:

• Low-dose PPI: ≤40 mg daily of esomeprazole, omeprazole, or pantoprazole; ≤30 mg lansoprazole 3
• Low-dose H2RA: ≤40 mg daily famotidine; ≤150 mg IV or ≤300 mg enteral ranitidine; ≤1200 mg cimetidine 3

Critical point: Use LOW-dose regimens only—high-dose SUP offers no additional benefit and should not be used. 1, 3 This is a good practice statement from the guidelines.

Route of Administration

Either enteral or intravenous routes are acceptable when administering SUP in high-risk patients. 1, 3 Choose based on patient's ability to tolerate enteral medications and hemodynamic stability.

Enteral Nutrition: Essential Component

Initiate early enteral nutrition in all critically ill adults to reduce stress-related bleeding (conditional recommendation, moderate certainty). 1 Enteral feeding decreases absolute bleeding risk by 0.3% (95% CI, 0.1–0.7) through direct mucosal protective mechanisms beyond acid suppression. 1, 2

However, enteral nutrition does NOT replace pharmacologic prophylaxis in high-risk patients. Even patients receiving enteral feeds should receive SUP if they have coagulopathy, shock, or chronic liver disease. 1, 3 One study suggested that surgical trauma patients tolerating full enteral nutrition may not need pharmacologic prophylaxis, 4 but the 2024 guidelines recommend continuing SUP in high-risk patients regardless of feeding status. 1

Potential risk: Concurrent administration of SUP with enteral nutrition may increase pneumonia risk, though the benefits of preventing bleeding in high-risk patients outweigh this concern. 1, 3

Duration and Discontinuation

Discontinue SUP when:

• Risk factors are no longer present (e.g., coagulopathy corrected, shock resolved) 1
• Critical illness is no longer evident 1
• Before transfer out of the ICU to prevent inappropriate continuation 1, 3

This is a good practice statement emphasizing that SUP should not be continued indefinitely. 1 The mortality from stress ulcer bleeding in critically ill patients is 48.5% compared to 9.1% in those without bleeding, making prevention critical during the high-risk period but unnecessary once risk factors resolve. 2, 5

Management of Active Bleeding Despite Prophylaxis

If bleeding develops despite prophylaxis:

• Urgent endoscopy (<12 hours) with dual-modality endoscopic hemostasis 5
• IV PPI bolus followed by continuous infusion for 72 hours post-hemostasis 5
• Target systolic BP 90-100 mmHg (permissive hypotension) and hemoglobin >7 g/dL (restrictive transfusion) 5
• Correct coagulopathy immediately 5

Common Pitfalls to Avoid

1. Starting SUP in all mechanically ventilated patients: Only those with additional risk factors (coagulopathy, shock, chronic liver disease) require prophylaxis. 1

2. Using high-dose regimens: No benefit over low-dose therapy. 1, 3

3. Continuing SUP after ICU transfer: This leads to inappropriate long-term PPI use. 1, 3

4. Relying on enteral nutrition alone in high-risk patients: Feeding reduces risk but does not eliminate the need for pharmacologic prophylaxis when risk factors are present. 1

5. Delaying prophylaxis: Must start immediately upon ICU admission in high-risk patients, not after bleeding develops. 5