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Erosive Gastritis

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Erosive Gastritis, Hemorrhagic Gastritis, Multiple Gastric Erosions, Stress Ulcer, Gastrointestinal Prophylaxis, Prophylaxis Against Gastrointestinal Ulcer, Gastric Ulcer Prophylaxis, Gastric Ulcer Prevention in Patients with Critically Illness

  • Causes
  1. See Peptic Ulcer Disease
  2. Medications
    1. Aspirin
    2. NSAIDs
    3. Alcohol
  3. Severe stress (mucosal protection breaks down, allows for splanchnic hypoperfusion)
    1. Burns
    2. Sepsis
    3. Trauma
    4. Surgery
    5. Shock
    6. Respiratory Failure
    7. Renal Failure
    8. Liver failure
    9. Mechanical Ventilation
  • Symptoms (May be asymptomatic)
  1. Epigastric discomfort
  2. Nausea or Vomiting
  3. Hematemesis
  4. Melena
  • Signs
  1. See Peptic Ulcer Disease
  2. Epigastric tenderness
  • Diagnosis
  1. Upper endoscopy (EGD)
    1. Mucosal inflammation and engorgement
    2. Erosions and Hemorrhages
  2. Upper GI barium study
    1. Thickened rugae
  • Prevention
  • Critically ill hospitalized patients (ICU)
  1. Indications: High risk patients in ICU
    1. Mechanical Ventilation
    2. Coagulopathy
    3. Multiple Traumatic injuries
    4. Recent Gastrointestinal Bleeding
    5. High dose Corticosteroids (equivalent to Prednisone 60 mg/day)
  2. Protocol
    1. Start GI prophylaxis in high risk ICU patients
      1. Risk of stress-ulcer related GI Bleeding in the ICU: 25%
    2. Discontinue prophylaxis on transfer out of Intensive Care unit
      1. Risk of Stress Ulcer related GI Bleeding drops to <1% outside the ICU
  3. General Measures
    1. Avoid NSAIDS in ICU patients
    2. Stop Aspirin in primary prevention (no known Coronary Artery Disease)
    3. Initiate early Enteral Nutrition
  4. Option 1: Maintain gastric pH > 4
    1. Proton Pump Inhibitor (PPI)
      1. Preparations
        1. Omeprazole (Prilosec) 20-40 mg orally daily
        2. Pantoprazole (Protonix) 40 mg IV daily
      2. Adverse effects
        1. Risk of Nosocomial Pneumonia (Protect against Aspiration Pneumonia)
        2. Risk of Clostridium difficile
      3. Efficacy
        1. May be more effective than H2 Blockers in ICU Stress Ulcer related GI Bleeding (variable evidence)
          1. Alhazzani (2013) Crit Care Med 41(3): 693-705 [PubMed]
    2. H2 Antagonist IV infusion
      1. Preparations
        1. Famotidine 20 mg IV every 12 hours
        2. Ranitidine 50 mg IV every 8 hours
        3. Avoid Cimetidine due to Drug Interactions
        4. Modify dose when GFR <50ml/min
      2. Efficacy
        1. May be preferred over PPI with fewer adverse effects
        2. Some studies suggest similar efficacy in prevention of GI Bleeding
        3. (2014) Presc Lett 21(4): 24
        4. MacLaren (2014) Crit Care Med 42(4): 809-15 [PubMed]
  5. Option 2: Topical protectants
    1. Sucralfate (carafate) slurry 1 g PO q6h
    2. Misoprostol 200 ug PO qid
    3. Less risk of Aspiration Pneumonia than Option 1
  • References
  1. Marino (2014) ICU Book, p. 77-88
  2. Internet Book of Critical Care (Farkas, EM-Crit)
    1. https://emcrit.org/ibcc/guide/