Stress-related mucosal damage: an overview.

Stress-related mucosal damage of the upper gastrointestinal tract occurs in the majority of critically ill patients. The more severe the underlying disease, the greater the chance that mucosal damage and subsequent bleeding will develop. Clinical outcome is determined by the type and severity of the underlying illness; however, cases with severe gastric damage, as diagnosed by endoscopic examination or by bleeding, have the poorest prognoses. Endoscopy is the most sensitive method for diagnosing stress-related mucosal damage. Other indicators of stress-related mucosal damage are macroscopic evidence of bleeding, blood transfusion requirement, or measures of occult bleeding; these tests cannot diagnose nonbleeding lesions. Low gastric pH values may also indicate physiologic response to stress, but such values are not uniformly correlated with the presence of injury. Vigorous acid suppression with prolonged periods of pH control may be necessary to treat stress-related mucosal damage and to prevent bleeding. Treatment modalities in current use include antacids, cimetidine, and other histamine (H2)-receptor antagonists, and, more recently, sucralfate. Current evidence indicates that antacids, given hourly and titrated to a present pH goal, or primed continuous infusion of cimetidine are the most efficacious regimens in maintaining intragastric pH control.