Stress Gastritis Prophylaxis

Stress Gastritis Prophylaxis

David Ray Velez, MD

Table of Contents

Indications
Agents

Also Referred to as “Stress Ulcer Prophylaxis” (SUP) or “GI Prophylaxis”

See Also:
*GI Bleeding

Indications

Guidelines are Highly Variable and Debated

Highest Risk Factors: Coagulopathy and Prolonged Mechanical Ventilation

2008 EAST Guidelines

  • Level 1 Recommendations:
    • Mechanical Ventilation
    • Coagulopathy
    • Traumatic Brain Injury
    • Major Burn Injury
  • Level 2 Recommendations:
    • Muti-Trauma
    • Sepsis
    • Acute Renal Failure
  • Level 3 Recommendations:
    • ISS > 15
    • High-Dose Steroids (> 250 mg Hydrocortisone or Equivalent per Day)

General Indications

  • Major Criteria:
    • Coagulopathy (INR > 1.5 or Plt < 50,000)
    • Mechanical Ventilation > 48 Hours (Especially if Not Taking Enteral Nutrition)
    • History of GI Ulcer or Bleed Within the Last Year
    • Traumatic Brain Injury
    • Spinal Cord Injury
    • Severe Burn Injury (TBSA > 35%)
  • Minor Criteria (≥ 2):
    • Sepsis
    • ICU Stay > 1 Week
    • Occult GI Bleeding for ≥ 6 Days
    • Steroid Therapy
  • Additional Possible Criteria:
    • Chronic Liver Failure
    • Partial Hepatectomy
    • NSAIDs
    • Antiplatelet Agents
    • Major Surgery
    • Multiple Organ Failure
    • GCS < 10
    • Hypotension
    • Myocardial Infarction
    • Multiple Organ Failure

Enteral Nutrition: Pharmacologic Stress Ulcer Prophylaxis is Considered Unnecessary and Not Beneficial if Patient is Tolerating Enteral Nutrition and May Increase the Risk of Nosocomial Pneumonia

  • Debated and Some Still Prefer to Use SUP in High-Risk Patients

Agents

Effects: Decreased Risk of Stress Ulcers, GI Bleeding, and Clinically Significant GI Bleeding

  • No Effect on Mortality or ICU Length of Stay

Agents

  • Proton Pump Inhibitor (PPI)
    • Agents:
      • Pantoprazole (Protonix) – 40 mg Daily PO or IV
        • 40 mg BID in the Setting of Confirmed GI Bleeding
      • Omeprazole (Prilosec) – 40 mg Daily PO
    • Mechanism: Irreversibly Blocks H/K ATPase Pump
  • Histamine-2 Receptor Antagonist (H2 Blocker)
    • Agents:
      • Famotidine (Pepcid) – 20-40 mg BID PO or IV
    • Mechanism: Blocks H2 Receptors on Parietal Cells

Oral and IV Effects are Equivalent

Comparison

  • PPIs are Generally Preferred
  • PPIs are More Effective than H2 Blockers
  • PPIs Do Not Require Dose Adjustment for Renal Failure
  • H2 Blockers Can Be Associated with Delirium
  • No Significant Difference in Most Side Effects

Side Effects

  • Increased Risk of Nosocomial Pneumonia (Debated)
  • Increased Risk of Clostridioides difficile Infection (Debated)
  • Increased Risk of Delirium with H2 Blockers