How to prevent and treat gastrointestinal bleeding in the critically ill patient: a pathophysiological approach

Stress ulceration and subsequent bleeding in critically ill patients shows an incidence of 2–6%. The pathophysiology is complex and begins with vasoconstriction. Mucosal ischemia ultimately leads to stress ulcer related bleeding (SURB). Upper gastrointestinal bleeding (UGIB) can also originate from other places, for instance reflux esophagitis, which has a different approach. Recently, it has become clear that acid suppression does not prevent UGIB or SURB. The meta-analyses on acid suppression are summarized in this review and show no clear effect on the incidence of UGIB or mortality. This knowledge urges us to reassess the pathophysiology of SURB. A conceptual model is presented based on pathophysiological studies. Insight in the pathophysiological process of SURB can lead to a multi-focused approach based on this conceptual model. In addition, a stepwise approach for the management of UGIB in critically ill patients is presented.