ICU · GI/Nutrition

Stress-related mucosal disease (stress ulcer prophylaxis)

Also known as Stress ulcer prophylaxis (SUP) · Stress-related mucosal disease (SRMD) · Curling ulcer (burns) · Cushing ulcer (TBI) · SUP-ICU trial · PEPTIC trial · REVISE trial

Stress-related mucosal disease (SRMD) is the rapid, ischaemia-driven breakdown of the gastric mucosal barrier in critical illness: splanchnic hypoperfusion → mucosal ischaemia → acid back-diffusion → superficial erosion (fundus/body). Subclinical erosions appear on endoscopy in 75-100% of ventilated patients within 24-72h, but clinically significant bleeding is rare (0.1-4%). Two independent risk factors dominate (Cook 1994, NEJM): mechanical ventilation 48h (1) and coagulopathy (INR 1.5 or platelets <50) — together they account for most clinically significant bleeding. Other: shock, sepsis, major burns 35% TBSA (Curling ulcer), severe TBI (Cushing ulcer), high-dose steroids. Prophylaxis is PPI first-line (pantoprazole 40 mg IV/PO daily — least CYP2C19 inhibition, clopidogrel-safe). Ranitidine globally WITHDRAWN (NDMA contamination) — use famotidine. Sucralfate is a mucosal protectant with lower C. diff risk but less effective. SUP-ICU trial (Krag 2018, NEJM): pantoprazole vs placebo reduced clinically significant bleeding (2.5% vs 4.2%, NNT 59) but did NOT reduce 90-day mortality and showed NO significant increase in pneumonia or C. difficile. PEPTIC (Young 2020, JAMA): PPI vs H2 blocker — no mortality difference. REVISE (Cook 2024, NEJM): confirms bleeding reduction without excess infection. Start SUP if risk factors present; STOP when tolerating enteral feeds + extubated + coagulopathy resolved. Enteral nutrition itself is protective. C. difficile risk is dose- and duration-dependent (~1.5x with PPI). Do NOT give SUP to ALL ICU patients — only those with indications. Review indication DAILY.