Acute upper gastrointestinal bleeding in critically ill patients: Causes and treatment modalities Steven A. Conrad, MD, PhD, FCCM A cute upper gastrointestinal bleeding is a common problem in critical care medicine. In the United States, it accounts for approximately 300,000 admissions to the hospital each year (1, 2). Optimal therapeutic management requires careful determination both of the bleeding’s sources and its characteristics. The vari- ous treatment options include endo- scopic interventional techniques and an- tisecretory therapy. Acid suppressives such as histamine-2–receptor antagonists (H 2 RAs) have been widely used in such patients for many years without evidence of efficacy. The superior acid suppression offered by proton pump inhibitors (PPIs) suggests that they will be more effective than H 2 RAs in controlling acute bleeding in a critical care setting. MORTALITY, SOURCES OF BLEEDING, AND COMPLICATING CONDITIONS The mortality rate for patients with acute upper gastrointestinal bleeding has remained relatively stable over the past 40 yrs; it ranges from 6% to 10% (3–5). These percentages may be misleading and should be lower because of significant improvements in management tech- niques and in transfusion practices. How- ever, such improvements apparently are offset by the increasing number of older patients with additional complications or with other co-morbid conditions and by a more widespread use of nonsteroidal an- ti-inflammatory drugs (1, 2, 6). Major causes of upper gastrointestinal bleeding in critically ill patients include variceal and acid-related sources. Variceal sources originate from the distal esopha- gus or the proximal gastric regions. Acid- related sources include peptic ulcer dis- ease and stress-related mucosal damage. Other less common conditions responsi- ble for upper gastrointestinal bleeding are Mallory-Weiss syndrome and vascular lesions. In the past 20 yrs, the distribu- tion of sources of such bleeding has changed little. Endoscopic surveys of large numbers of patients have revealed that up to 75% of upper gastrointestinal bleeding results from acid peptic disease. Gastritis, gastric ulcer, and duodenal ul- cer occur in approximately equal num- bers (3, 7). Varices, esophagitis, duodeni- tis, and Mallory-Weiss syndrome each account for 5% to 15% of the remaining cases. Complicating conditions include co- agulopathy and splanchnic ischemia. He- mostatic disorders such as platelet disor- ders and disorders of coagulation factors present considerable problems. Although the role of splanchnic ischemia is not well defined, a consensus exists that mu- cosal hypoperfusion may play an integral part in the pathogenesis of some of these lesions, particularly in the case of reper- fusion injury that occurs after the state of shock (8, 9). GENERAL MANAGEMENT APPROACHES TO ACUTE BLEEDING Bleeding stops spontaneously in most patients (10), but aggressive manage- ment is required when bleeding does not quickly resolve or when patients are at high risk for rebleeding. Management From the Department of Medicine and Emergency Medicine, LSU Health Sciences Center, Shreveport, LA. Address requests for reprints to: Steven A. Conrad, MD, Department of Medicine and Emergency Medi- cine, LSU Health Sciences Center, 1501 Kings High- way, P.O. Box 33932, Shreveport, LA 71130-3932. E-mail: sconrad@lsuhsc.edu Copyright © 2002 by Lippincott Williams & Wilkins Upper gastrointestinal bleeding from peptic ulcers or other nonvariceal causes generally stops spontaneously; if it fails to do so, aggressive management is required. Such measures also are necessary for patients at high risk for rebleeding. Endoscopic therapy achieves hemostasis in >90% of bleeding patients and reduces mortality. After successful hemostasis of the initial bleeding episode, the primary concern becomes the prevention of rebleeding, which occurs in up to 20% of patients. Acid suppres- sion with histamine-2–receptor antagonists has been widely used for many years to prevent recurrent bleeding. However, in acutely bleeding patients, these agents have not been shown to reduce the number of episodes of further bleeding or rebleeding or to reduce the need for transfusions or surgery. Omeprazole, an intravenous proton pump inhibitor, significantly reduced the rate of rebleeding in a recent placebo-controlled trial in which only patients with endoscopic confirmation of successful hemostasis were enrolled. Although this drug does not seem to reduce the need for surgical intervention or to decrease mortality, the trial does indicate the promise of intravenous proton pump inhibitors in reducing upper gastrointestinal bleeding. Evidence from addi- tional well-controlled trials is needed to confirm this finding. The use of proton pump inhibitors in this setting also may have a positive economic impact, and a decrease in the percentage of patients who experience rebleeding will eliminate the cost of further management strategies in those cases. (Crit Care Med 2002; 30[Suppl.]:S365–S368) KEY WORDS: peptic ulcer rebleeding; upper gastrointestinal bleeding; Helicobacter pylori; prophylaxis; treatment; endoscopy; hemostasis; intravenous; proton pump inhibitors; pantoprazole; histamine-2–receptor antagonists; cost of therapy S365 Crit Care Med 2002 Vol. 30, No. 6 (Suppl.)