GI Prophylaxis

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Introduction

1832 Cushing reported ulcer disease

associated with surgery and trauma 1842 Curling described a series of severe

duodenal ulceration associated with burns

Strong association with severe illness and

incidence of GI bleeds have been established Major bleeds have a high mortality rate

Prophylaxis now a central ICU issue


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What is Stress Ulceration?

Gastrointestinal mucosal injury related to

critical illness Incidence related to severity illness [1]

Not related to H.pylori or existing peptic ulcer

Multifactorial Hypoperfusion

Loss of host defences


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Why is it important

Mortality with bleeding extremely high

48.5% [2]

87.5% [3]

This poor outcome probably a reflection of

patients severity of illness rather than bleeditself


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What causes it?


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What causes it?

Damaged mucosa

Reduced mucosal blood flow Leads to:

Reduced prostaglandins

Mucosal Atrophy

Increased permeability Loss of ability to neutralise H+ ions

Loss of reparative ability


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Risk factors

2 studies by Cooke`s group [2,4]

Respiratory failure Coagulopathy

Sepsis

Liver failure

Hypotension

Renal Failure

Duration of Stay

Multiple of above risk factors(burns)


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Treatment

Antacid

Sucrulfate H2RA

PPI

Enteral nutrition General Measures


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Cook et al JAMA 1996

Type of medical

therapy

compared withPlacebo or

Control

Relative risk of

o

Relative risk of

important

bleeding

Relative risk of

death

Antacids 0.66 (0.37-1.17) 0.35(0.09-1.41) 1.42(0.82-2.47)

Sucrulfate 0.58(0.34-0.99) 1.26(0.12-

12.87)

1.06(0.67-1.67)

H2 antagonists 0.58(0.42-0.79) 0.44(0.22-0.88) 1.15(0.86-1.53)


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Cook DJ et al New Eng j 1998

Relative risk of

o

Relative risk of

important

bleeding

Relative risk of

death

H2 antagonist

vs sucralfate

0.44(0.21-0.92) 1.18(0.92-1.51) 1.03(0.84-1.26)


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Treatment

Evidence suggests that bleeding, but not

mortality can be reduced, by all agents. [7] Evidence suggests that H2 receptor

antagonists are most efficient in reducing overt

and clinically important bleeding in ICU

patients. [4]

Enteral nutrition and ranitidine protect against

bleeding, and an additive effect is seen. [8]


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PPI

Effectively suppresses gastric pH levels in the

ICU patient PPI`s superior to H2RAs for PUD and GRD

Data extrapolated in SRMB

Omeprazole found to be superior than

ranitidine in preventing SRMB[9]

Groups not equal regarding risk


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PPI

Several studies concluded agents were safe

and as effective as an alternative to H2RA Small studies

Need for further clinical trials


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Enteral Nutrition

Cook et al protective effect of enteral feeding

for prevention SRMB (relative risk 0.30)[8] Inconclusive results for enteral feeding being

used as SUP[9]

Cannot be recommended as sole agent[10]


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Treatment Strategy

No current evidence that patients without 1 of 6

major risk factors warrant prophylaxis Shock

Sepsis

Resp failure

Hepatic failure

Renal failure

Coagulopathy


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Treatment Complications

Nosocomial pneumonia

Anti-acid therapy promotes colonisation of gutmucosa

Aspiration may cause pneumonia [6][11]

Sucralfate doesnt alter gastric pH

Pnuemonia rates with ranitidine and sucralfate

not statistically different[12]


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Treatment Complications

Nosocomial pneumonia H2RA vs PPI

14% patients on ranitidine developed NP

3% patients on omeprazole developed NP [13]


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Discussion and Questions


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References

[1] - Pruitt BA, Jr., Foley FD, Moncrief JA.

Curling's ulcer: a clinical-pathology study of323 cases.Ann Surg1970; 172(4):523-539.

[2] Cook DJ, Fuller HD, Guyatt GH, Marshall

JC, Leasa D, Hall R et al. Risk factors for

gastrointestinal bleeding in critically ill patients.Canadian Critical Care Trials Group. NEngl J

Med 1994; 330(6):377-381.


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References

[3] Skillman JJ, Bushnell LS, Goldman H, Silen W.Respiratory failure, hypotension, sepsis, and jaundice.

A clinical syndrome associated with lethal hemorrhagefrom acute stress ulceration of the stomach.Am J Surg1969; 117(4):523-530.

[4] Cook D, Guyatt G, Marshall J, Leasa D, Fuller H,Hall R et al. A comparison of sucralfate and ranitidinefor the prevention of upper gastrointestinal bleeding inpatients requiring mechanical ventilation. CanadianCritical Care Trials Group. NEngl J Med1998;338(12):791-797.


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References

[5] Shuman RB, Schuster DP, Zuckerman GR.

Prophylactic therapy for stress ulcer bleeding:a reappraisal.Ann Intern Med1987;106(4):562-567.

[6] Cook DJ, Walter SD, Cook RJ, Griffith LE,Guyatt GH, Leasa D et al. Incidence of and riskfactors for ventilator-associated pneumonia incritically ill patients.Ann Intern Med1998;129(6):433-440.


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References

[7] Cook DJ et al JAMA 1996

[8] Cook DJ et al. CritCare Med 1999; 27:2812 [9] Raff et al Burns 1997; 23:313-318

[10] MacClaren et al: Use of enteral nutrition for stress

ulcer prophylaxis.Ann Pharmacother2001;35:1614-

1623

[11]Tryba :role of acid suppressants in intensive care

medicine. Best Pract Res Clin Gastroenterol


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References

[12]Tryba M: Sucalfate vs antacids or H2RA

for SUP: A meta-analysis on efficacy andpneumonia rate. CritCare Med1990;16:44-49

[13] Levy et al :Comparison of omeprazole and

ranitidine for SUP DigDis Sci1997 42:1255-

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