Prevention of gastrointestinal bleeding due to stress ulceration: a review of current literature

• Published in: Anaesthesia and intensive care Vol. 40; no. 2; pp. 253 - 259
• Main Authors: PILKINGTON, K. B, WAGSTAFF, M. J. D, GREENWOOD, J. E
• Format: Journal Article
• Language: English
• Published: Edgecliff Anaesthesia Society of Anaesthetists 01.03.2012; Sage Publications Ltd. (UK); Sage Publications Ltd
• Subjects: Anesthesia; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Anti-Ulcer Agents - adverse effects; Anti-Ulcer Agents - economics; Anti-Ulcer Agents - therapeutic use; Biological and medical sciences; Complications and side effects; Enteral Nutrition; Gastric Acid - metabolism; Gastrointestinal bleeding; Gastrointestinal Hemorrhage - drug therapy; Gastrointestinal Hemorrhage - etiology; Gastrointestinal Tract - blood supply; Health aspects; Humans; Hydrogen-Ion Concentration; Medical sciences; Prevention; Proton pump inhibitors; Proton Pump Inhibitors - therapeutic use; Randomized Controlled Trials as Topic; Ranitidine - therapeutic use; Regional Blood Flow - physiology; Risk factors; Stomach Ulcer - complications; Stomach Ulcer - drug therapy; Stomach Ulcer - etiology; Stress, Psychological - complications; Stress, Psychological - drug therapy; Treatment Outcome; Ulcers; Australia; burn injury; stress-related muscosal disease; Stress; Proton pump inhibitor; upper gastrointestinal bleeding; Burn; Prevention; histamine-2 receptor antagonists; proton pump inhibitors; Gastrointestinal bleeding; Digestive diseases; Intestinal disease; Anesthesia; Histamine receptor; Ulceration
• ISSN: 0310-057X; 1448-0271
• DOI: 10.1177/0310057x1204000207

Our objective was to audit our current stress ulcer prophylaxis protocol (routine prescription of ranitidine and early enteral feeding) by identifying whether routine prescription of histamine-2 receptor antagonists or proton pump inhibitors as prophylaxis against stress-related mucosal disease and subsequent upper gastrointestinal bleeding is supported in the literature. We also aimed to ascertain what literature evidence supports the role of early enteral feeding as an adjunctive prophylactic therapy, as well as to search for burn-patient specific evidence, since burn patients are at high risk for developing this condition, with the aim of changing our practice. PubMed and Cochrane databases were searched for relevant articles, yielding seven randomised controlled trials comparing histamine-2 receptor antagonists and proton pump inhibitors in the prevention of upper gastrointestinal bleeding associated with stress-related mucosal disease and three separate meta-analyses. Despite level 1 clinical evidence, no significant difference in efficacy between histamine-2 receptor antagonists and proton pump inhibitor treatment groups was demonstrated. No significant difference was demonstrated in the incidence of nosocomial pneumonia between the two drugs given in this indication. However, enteral feeding was found to be safe and effective in preventing clinically significant upper gastrointestinal bleeding. Patients able to tolerate feeds demonstrated no additional benefit with concomitant pharmacological prophylactic therapy. Since all burn patients at the Royal Adelaide Hospital are fed from very early in their admission, the literature suggests that we, like our intensive care unit colleagues, should abolish our reliance on pharmacological prophylaxis, the routine prescription of which is not supported by the evidence.