What is the recommended treatment for a critically ill patient with stress gastritis?

Treatment of Stress Gastritis in Critically Ill Patients

For critically ill patients with stress gastritis and risk factors for bleeding, initiate either a proton pump inhibitor (PPI) or histamine-2 receptor antagonist (H2RA) at low doses, along with enteral nutrition when feasible. 1

Risk Stratification and Treatment Indications

High-Risk Patients Requiring Prophylaxis

• Mechanical ventilation >48 hours (odds ratio 15.6 for clinically important bleeding) 2
• Coagulopathy (odds ratio 4.3 for bleeding) 1, 2
• Shock states (particularly hypovolemic or septic shock) 1, 3
• Chronic liver disease 1

Patients with both respiratory failure and coagulopathy have a 3.7% bleeding risk, with mortality reaching 48.5% if bleeding occurs versus 9.1% without bleeding. 3, 2

Low-Risk Patients NOT Requiring Prophylaxis

• Patients without respiratory failure or coagulopathy have only 0.1% bleeding risk 2
• Do not initiate prophylaxis in enterally fed patients at low risk 1

Pharmacologic Treatment Algorithm

First-Line Agent Selection

Either PPIs or H2RAs are acceptable first-line agents with equivalent recommendations. 1 However, the evidence reveals important nuances:

• PPIs reduce clinically important bleeding more than H2RAs (RR 0.53,95% CI 0.34-0.83) 1
• PPIs may increase mortality slightly (RR 1.05,95% CI 1.0-1.10) compared to H2RAs 1
• In patients with severe liver disease (e.g., MELD ≥35), prefer PPIs due to more consistent acid suppression 3

Dosing Specifications (Good Practice Statement)

"Low-dose" regimens should be used: 1

PPIs (daily dose):

• Esomeprazole, omeprazole, or pantoprazole: ≤40 mg
• Lansoprazole: ≤30 mg

H2RAs (daily dose):

• Famotidine: ≤40 mg
• IV ranitidine: ≤150 mg
• Enteral ranitidine: ≤300 mg
• Cimetidine: ≤1200 mg

Route of Administration

Either enteral or IV routes are acceptable with no firm evidence favoring one over the other. 1 Choose based on patient's ability to tolerate enteral medications and IV access availability.

Adjunctive Therapy

Enteral Nutrition

Initiate enteral nutrition when feasible to reduce bleeding risk. 1 Even in enterally fed patients with risk factors (mechanical ventilation, coagulopathy, shock, chronic liver disease), continue prophylaxis as enteral nutrition alone is insufficient protection. 1, 3

Duration and Discontinuation Strategy

When to Discontinue (Good Practice Statement)

Discontinue prophylaxis when: 1

• Risk factors are no longer present (extubated, coagulopathy resolved, shock resolved)
• Before ICU transfer to prevent inappropriate continuation
• Critical illness has resolved

Common Pitfall to Avoid

Inappropriate continuation beyond ICU discharge is a major problem. 1 PPIs in particular tend to be continued unnecessarily after ICU discharge. Review indications at ICU discharge and discontinue if no ongoing indication exists. 1

Patients on Prophylaxis Before ICU Admission

• Without current risk factors: Review indications and consider discontinuation 1
• With current risk factors: Weigh changing to preferred ICU agent against pre-existing indication 1

Important Safety Considerations

Potential Complications

• Pneumonia risk: Sucralfate shows lower pneumonia rates than PPIs (RR 0.49) or H2RAs (RR 0.83), though many studies used outdated pH targets 1
• Mortality signal with PPIs: Network meta-analyses suggest possible increased mortality with PPIs versus H2RAs, though certainty is limited 1
• Clostridium difficile: Not adequately studied in prophylaxis trials 1

Agents NOT Recommended

Do not use concurrent sucralfate with acid suppressants - no evidence supports combination therapy. 1