Clinically significant gastrointestinal bleeding in critically ill patients in an era of prophylaxis

OBJECTIVE: Clinical studies examining stress-related gastrointestinal bleed ing in critically ill patients vary in their clinical definitions and asses sment of clinical significance. Although there is evidence that routine pro phylaxis decreases stress-related gastrointestinal bleeding, recent studies indicate a decreasing incidence, independent of the use of prophylactic me dications. The purpose of this study was to determine the incidence of and risk factors for clinically significant, endoscopically proven gastrointest inal bleeding in critically ill patients. METHODS: A database (prospectively collected data) of 8338 patients admitte d to the surgical and medical intensive care units at major tertiary care c enter from July 1988 to April 1995 was examined. All patients with signific ant upper gastrointestinal bleeding as defined by a drop in hemoglobin of > 20 g/L and endoscopic evidence of an upper GI tract source were identified. Risk factors for GI bleeding from stress ulceration were compared in bleed ing and nonbleeding patients. A case-control study analyzing risk factors f or bleeding in the abdominal aortic aneurysm subgroup was performed. RESULTS: After exclusion criteria, 12/7231 (0.17%) patients had clinically significant, endoscopically proven bleeding. Significant risk factors inclu ded age, septic shock, abdominal aortic aneurysm repair, and nutritional su pport. Intensive care unit stay was prolonged in patients with stress-relat ed bleeding. There was no difference in incidence of hypotension, clamp tim e, APACHE score, or operating room time in patients with abdominal aortic a neurysm repair as compared with controls. CONCLUSIONS: In an intensive care unit where stress prophylaxis is widely u sed, clinically important gastrointestinal bleeding is uncommon. Further st udy is needed to define the optimal prophylaxis regimen and the role for it s selective use-in high-risk patients. (Am J Gastroenterol 2000;95: 2801-28 06. (C) 2000 by Am. Coll. of Gastroenterology).