الفهرس 
Normal defense mechanism against ulcerationOnly 14 pages are availabe for public view
 |  | from | 106 |  |  |
| | | from | 106 | | |
Abstract
Stress is defined as a response to severe demands on the human body resulting in the disruption of homeostasis through physical and psychological stimuli. It has long been recognized that severe physiologic stress can cause gastric mucosal damage. Stress-related mucosal disease (SRMD) is an acute, erosive gastritis representing conditions ranging from stress-related injury to stress ulcers. Stress-related injury is superficial mucosal damage that presents primarily as erosions, whereas stress ulcers are deep, focal mucosal damage penetrating the submucosa with high risk for gastrointestinal bleeding. Mucosal damage has been reported to occur during the first 24 hours of hospital admission in 75% to 100% of intensive care unit (ICU) patients
Occult bleeding is usually defined as positive guiac test on fecal sample without overt GI bleeding; overt bleeding is defined as hematemesis, coffee ground emesis, melena or bloody nasogastric aspirate; clinically important bleeding (CIB) is usually defined as overt bleeding plus one of the following four features in the absence of other causes: a spontaneous DROP of systolic or diastolic blood pressure of 20 mmHg or more within 24 hours of upper gastrointestinal bleeding, an orthostatic increase in pulse rate of 20 beats per minute and a decrease in systolic blood pressure of 10 mmHg, a decrease in haemoglobin of at least 2 g/dl (20 g/l) in 24 hours or transfusion of 2 U packed red blood cells within 24 hours of bleeding
The majority of stress ulcerations are asymptomatic and clinically insignificant. Mucosal injury is found in greater than 75% of critically ill patients within 24 hours of admission. The typical mucosal injury seen is multiple, diffuse, superficial erosions in the gastric fundus and body; however, focal, deep ulceration can also be seen in both the stomach and the duodenum
Recommendation for pharmacologic intervention in adults admitted to the ICU who have coagulopathy, require mechanical ventilation for >48 hrs, have a history of gastrointestinal ulceration or bleeding within 1 yr before admission, or have at least two of the following risk factors: sepsis, ICU stay of >1 wk, occult bleeding lasting ≥6 days, and use of >250 mg of hydrocortisone or the equivalent.
Adverse effects associated with chronic use may be important, as around a third of patients given PPIs for stress ulcer prophylaxis went home on the drug despite there being no indication on discharge from hospital for their continued use .
Mortality/morbidity figures are high in older patients because of several factors, including atherosclerosis that leads to reduced blood supply and impaired host defenses. The severity of the injury leads to a further reduction in blood flow to the GI tract, thereby resulting in further compromise of the mucosal barrier and an increased risk of gastritis. The presence of Helicobacter pylori may also contribute to the mucosal barrier breakdown and lead to stress ulcer .
Introduction by pharmacists of a treatment algorithm for stress-ulcer prophylaxis in ICUs has been shown to allow a reduction of inappropriate prescriptions and, thus, a reduction in the cost of drugs. Adherence to published guidelines for stress-ulcer prophylaxis will prevent unwanted side effects of medications and will also be cost-effective