How is stress ulcer-related upper gastrointestinal bleeding (UGIB) treated?

Updated: Aug 12, 2019
  • Author: Bennie Ray Upchurch, III, MD, FACP, AGAF, FACG, FASGE; Chief Editor: BS Anand, MD  more...
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Answer

Knowledge of the predisposing conditions for stress ulceration allows the clinician to identify patients at risk for developing stress ulceration and gastrointestinal (GI) bleeding—respiratory failure with mechanical ventilation and coagulopathy being very prominent risk factors. Treatment in this group of high-risk patients should focus on prevention. This is best accomplished by treating the underlying causes of ulceration.

Aggressive support of hemodynamic parameters ensures adequate mucosal blood flow. In addition, several strategies have evolved to treat gastric luminal acidity.

Stress-related bleeding usually occurs 7-10 days after the initial insult but may manifest sooner. Initially, endoscopy is the most important diagnostic tool. The acute superficial erosions are multiple, begin in the fundus, and progress toward the antrum. Ninety percent of patients stop bleeding with conservative medical therapy that includes gastric acid–controlling medications to maintain the gastric luminal pH above 5.0. [18]

PPIs are the drugs of choice for acid suppression in stress ulcer prophylaxis (SUP). The risk of bleeding in an intensive care unit (ICU) is reduced by some 60% in patients receiving SUP compared to those treated with placebo or no prophylaxis. [153]  Current evidence does not substantiate routine prophylaxis. Therefore, withhold SUP in the majority of hospitalized patients, unless they have multiple risk factors and are likely to benefit from preventative strategies. Both cost and potential side effects from unnecessary proton-pump inhibitor (PPI) use can be reduced from following these guidelines. [92, 124]

Endoscopic hemostasis is attempted using traditional techniques, including electrocoagulation, argon plasma coagulation (APC), or injection therapy. Selective angiographic catheterization of the left gastric artery may be attempted with selective infusion of vasopressin (48-72 h) or embolization using Gelfoam, coils, or autologous clot to embolize the left gastric artery. Regardless of the angiographic technique used, it is often unsuccessful because of the rich and extensive submucosal plexus and collateral circulation within the stomach.


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