Risk Factors for Stress Ulcers
The primary risk factors for stress-related gastric or duodenal ulcers in critically ill adults are coagulopathy, shock, and chronic liver disease, while mechanical ventilation alone is not an independent risk factor. 1, 2
Critical Care Setting Risk Factors
The 2024 Society of Critical Care Medicine guidelines definitively identify three major risk factors that substantially increase the likelihood of clinically important stress-related upper gastrointestinal bleeding:
High-Risk Conditions
- Coagulopathy increases the absolute risk of stress-related bleeding by 4.8% (95% CI, 2.6–8.6%) 2
- Shock increases the absolute risk by 2.6% (95% CI, 1.2–5.4%) 2
- Chronic liver disease increases the absolute risk by 7.6% (95% CI, 3.3–17.6%) 2
Important Clarification on Mechanical Ventilation
There is no conclusive evidence that mechanical ventilation alone is an independent risk factor for stress ulcers. 2 This represents a significant departure from historical teaching—mechanical ventilation by itself does not necessitate stress ulcer prophylaxis unless accompanied by one of the three major risk factors listed above. 2
Additional Risk Factors in Critical Illness
- Sepsis is recognized as a risk factor for stress ulcer development 3
- Multiple organ failure increases ulcer risk 3
- Major trauma (especially severe injuries and burns) predisposes to stress ulceration 3, 4
- Major surgery is associated with increased risk 3
- Peritonitis and chronic medical illness contribute to ulcer formation 5
Non-Critical Care Risk Factors
Psychological Stress
High levels of perceived everyday life stress more than double the risk of peptic ulcer disease. 6 In a prospective Danish cohort study:
- The highest stress group had a 2.2-fold increased risk (HR 2.24; 95% CI 1.16–4.35) compared to the lowest stress group 6
- This effect persisted after adjusting for age, gender, socioeconomic status, NSAID use, and health behaviors 6
- Psychological stress increased ulcer incidence independent of H. pylori infection status and NSAID use 7
Medication-Related Risk Factors
- NSAID use is a well-established independent predictor of peptic ulcer disease 7, 8
- Glucocorticoids can induce ulcer formation 4
- Salicylates and anti-rheumatic drugs are predisposing factors 4
Infectious and Other Factors
- Helicobacter pylori infection remains an independent predictor of ulcer development 7, 8, 9
- Smoking is an independent risk factor 7
- Low socioeconomic status independently predicts ulcer occurrence 7
- Lack of exercise contributes to increased risk 7
Clinical Implications
Critically ill adults with any of the three major risk factors (coagulopathy, shock, or chronic liver disease) should receive stress ulcer prophylaxis with either proton pump inhibitors or histamine-2 receptor antagonists. 1, 2 The absence of enteral nutrition does not eliminate the need for prophylaxis in high-risk patients, though enteral nutrition itself probably reduces bleeding risk. 1, 2
Common Pitfall to Avoid
Do not automatically prescribe stress ulcer prophylaxis for all mechanically ventilated patients—this represents inappropriate prescribing unless other risk factors are present. 1 Prophylaxis should be discontinued when critical illness resolves or risk factors are no longer present, and must be stopped before ICU transfer to prevent continuation outside the appropriate clinical context. 1