Prophylaxis for stress-related gastrointestinal hemorrhage

The incidence of clinically important stress-related gastrointestinal hemorrhage (SRGIH) has decreased without the use of prophylaxis. This decline is probably attributable to improved care in the modern intensive care unit: aggressive correction of hypovolemia, adequate respiratory support, maintenance of tissue perfusion, and improved nutritional support. The majority of patients admitted to intensive care units are not at risk of developing clinically important SRGIH. Patients who are at high risk for SRGIH, and who may, therefore, benefit from prophylaxis, are those with at least one of the factors listed in Table 1. Antacids, histamine type 2-receptor antago-nists (H2 RA), proton pump inhibitors, and sucralfate all provide comparable protection from SRGIH. The choice of pharmacologic agent for prophylaxis therefore depends on other considerations, such as cost, side effects, and ease of administration. In this regard, it is still unclear whether these prophylactic medications increase the inci-dence of nosocomial pneumonia when administered to intensive care unit patients. Antacids may pose the greatest risk for developing pneumonia, followed by H2RA, and sucralfate. More research is necessary to resolve this important issue. Pharmacologic prophylaxis for SRGIH is cost effective only in high- risk populations. Based on existing literature, the cost of using of routine prophylaxis is prohibitive for at least two-thirds of patients admitted to intensive care units who are at low risk of SRGIH. When prophylaxis is administered to high-risk patients, the cost-per-averted-bleeding episode for sucralfate is lower than for other medications.