STRESS ULCER SYNDROME IN INTENSIVE CARE UNIT PATIENTS

Abstract

Stress ulcers are erosions or ulcers in upper gastrointestinal tract with extreme physiological stress. When associated with critical bleeding or perforation the condition is called Stress ulcer syndrome. Within the first 24 hours after ICU admission, approximately 75% to 100% of critically ill patients have some Endoscopic evidence of gastroduodenal or upper gastrointestinal lesions. Clinical risk factors commonly associated with stress ulcer syndrome include major surgery, hemorrhagic shock, hypotension, long-term mechanical ventilation, coagulopathy, trauma and sepsis. The precise etiology of stress ulceration is not known. Mucosal ischemia is thought to be the common denominator in the pathogenesis of stress ulceration not gastric acidity. Helicobacter pylori infection doesn’t present as a clear causal association as does with duodenal ulcer. Multiple physiologic and iatrogenic factors play a role in the development or exacerbation of stress ulcers. However, only two risk factors have been shown to contribute to clinically significant gastrointestinal bleeding in ICU patients: (1) respiratory failure requiring mechanical ventilation for at least 48 hours and (2) coagulopathy. Stress ulcers are frequently asymptomatic and come to clinical attention only when they manifest bleeding. Hematemsis or melena is the unusual presentation occurring in 20 % of patients at risk. Measures to improve heamodynamic parameters should restrict use of the vasopressors when possible because use of these agents can worsen ischemia of the gastrointestinal tract. If possible, early enteral nutrition should be considered in most critically ill patients. Stress ulcer prophylaxis is far better than trying to treat it once it occurs. Prophylactic agents include antacids, H2-receptor blockers, sucralfate, proton pump inhibitors (PPls), prostaglandin analogues, and nutrition. Overt bleeding of stress ulcer requires investigation by endoscopy. Endoscopy with or without intervention is the current accepted standard management. Surgical therapy can be used if bleeding can’t be controlled.