What is the recommended prophylaxis and treatment for Cushing‑type stress ulcers in patients with severe burns, major trauma, major surgery, sepsis, or high‑dose corticosteroid therapy?

Management of Cushing Ulcers

Stress ulcer prophylaxis should be initiated immediately in all critically ill patients with risk factors including mechanical ventilation >48 hours, coagulopathy, sepsis, major burns, or severe trauma using either proton pump inhibitors or H2-receptor antagonists, with PPIs preferred in highest-risk patients. 1, 2

Risk Stratification and Indications for Prophylaxis

High-Risk Patients Requiring Prophylaxis (Grade A Evidence)

• Mechanical ventilation for ≥48 hours 1
• Coagulopathy (strongest predictor with OR = 4.3) 2, 3
• Sepsis or septic shock 1
• Major burns, severe trauma, or major surgery 2, 4, 5
• Hypotension or hypovolemic shock 2, 5

Moderate-Risk Patients (Grade C Evidence)

• Acute kidney injury 2
• Multiple organ failure 2
• High-dose corticosteroid therapy (though recent evidence questions direct ulcerogenic effect) 6

Patients NOT Requiring Prophylaxis

• Absence of risk factors (bleeding risk only 0.2%) 1
• Low-risk patients should not receive prophylaxis due to cost and potential complications 1

Pharmacologic Prophylaxis Regimen

First-Line Options

Proton Pump Inhibitors (Preferred)

• Intravenous pantoprazole 40 mg daily for critically ill patients unable to take oral medications 2, 3
• PPIs provide more consistent acid suppression than H2-receptor antagonists 2
• Particularly preferred in patients with severe liver disease (e.g., MELD ≥35) due to reduced hepatic metabolism concerns 2

H2-Receptor Antagonists (Acceptable Alternative)

• Ranitidine or cimetidine are equivalent alternatives when PPIs unavailable 1
• Both drug classes considered equivalent by 2016 Surviving Sepsis Campaign 2, 3
• Cimetidine and antacids reduce stress ulcer bleeding 33% and 43% respectively compared to control 1

Historical Context

While older guidelines (2012) suggested preferring PPIs over H2RAs (grade 2C) 2, the more recent 2016 Surviving Sepsis Campaign considers both equivalent options 2, 3. In clinical practice, PPIs remain preferred for highest-risk patients due to superior acid suppression. 2

Adjunctive Measures

Enteral Nutrition

• Early enteral nutrition provides additional protection against stress ulceration when tolerated 1, 2
• Distal enteral nutrition more beneficial than gastric feeding 1
• Cannot replace pharmacologic prophylaxis but serves as important adjunct 1

Antacids (Historical Option)

• Hourly titration with antacids to maintain gastric pH ≥3.5 was previously standard 4
• Antacids and H2-antagonists equally effective in older studies 1, 4
• Largely replaced by PPIs/H2RAs due to ease of administration 1

Timing and Duration

Initiation

• Prophylaxis must be started immediately upon ICU admission 2, 3
• Do not delay for stool cultures or diagnostic workup in suspected high-risk patients 2
• Stress ulcers can develop within 24-48 hours of critical illness onset 2

Duration

• Continue prophylaxis as long as risk factors persist 2, 3
• Discontinue when sepsis resolves AND patient tolerates enteral nutrition 2, 3
• Reevaluate need daily based on clinical status 3
• Extending therapy beyond 7-10 days in acute severe ulcerative colitis carries no additional benefit and increases toxicity 1

Monitoring Requirements

Clinical Surveillance

• Monitor for signs of GI bleeding from admission: melena, hematemesis, drop in hemoglobin 2, 3
• Bleeding typically occurs between days 5-10 after admission 7
• Mortality significantly higher in patients who develop bleeding (48.5% vs 9.1%) 2

Laboratory Monitoring

• No routine systemic monitoring required for short-term prophylaxis 8
• Assess for hypothalamic-pituitary-adrenal axis suppression only with prolonged use (>2-3 weeks) of rectal corticosteroids 8

Treatment of Established Bleeding

Medical Management (First-Line)

• Saline lavage, adequate supportive measures, and continued acid suppression 4
• Most episodes resolve with medical management alone 4, 5
• For active bleeding: PPI loading dose followed by continuous infusion for 72 hours 2

Interventional Options

• Endoscopy for diagnosis and potential therapeutic intervention 4
• Pharmacoangiography with selective vasopressin infusion or embolization for continued bleeding 4

Surgical Management (Last Resort)

• Surgery carries predictably high mortality 4, 5
• Vagotomy, pyloroplasty, and oversewing ulcers as initial operation 4
• Near-total gastrectomy for continued bleeding after initial surgery 4
• Exsanguinating hemorrhage carries extremely high morbidity and mortality 5

Critical Pitfalls to Avoid

• Do not withhold prophylaxis in patients with multiple risk factors 2, 3
• The combination of mechanical ventilation >48 hours plus coagulopathy dramatically increases bleeding risk 2, 3
• Do not confuse topical/rectal corticosteroid dosing with systemic stress ulcer risk 8
• Prophylaxis in low-risk patients is cost-prohibitive and not recommended 1
• Be aware that PPI use may increase risk of hospital-acquired pneumonia, though this should not prevent use in high-risk patients 2
• Risk factors for stress ulcer bleeding are additive - patients with multiple factors require aggressive prophylaxis 1