Upper Gastrointestinal Bleeding in the Absence of Proper pH Control in Patients Admitted to ICU

Introduction: Stress-related mucosal disease (SRMD) occurs in many critically ill patients in Intensive Care Units (ICU) and may develop within 24 hours of admission. Proton pump inhibitors (PPI) therapy has been documented to produce more potent inhibition of gastric acid secretion than Histamine 2 Receptor Antagonists (H2RAs) and suspension preparations can increase the gastric pH more than intravenous PPIs. The incidence of clinically important gastrointestinal (GI) bleeding, indicated as overt bleeding complicated by hemodynamic instability, low hemoglobin, and/or need for a blood transfusion from stress-related mucosal disease (SRMD) is 3.5% in the ICU patients who are mechanically ventilated for ≥ 48 h. In addition, this type of ulceration is accompanied by increasing the risk of mortality. Moreover, it prolongs the length of stay in the ICU. Although ischemia of the gastric mucosa leads to SRMD, the significant role of gastric acid in the development of mucosal damage and bleeding could not be ignored. Thus, early preventive prophylaxis of the probable GI bleeding, by means of acid-reducing agents, in these patients is rational Studies have shown that patients with gastrointestinal bleeding are admitted for longer periods of time to ICU. The role of gastric acid in the development of SRMD and the need for early intervention to prevent the potential occurrence of upper gastrointestinal bleeding have led to the preventive use of gastric acid-reducing agents in patients admitted to ICU. Therefore, this study evaluated the effect of omeprazole oral suspension in increasing gastric pH and compare it with the previous study which has been done in the same center, followed by upper gastrointestinal bleeding that may occur due to lack of proper pH control in patients admitted to ICU.

Methods: Patients were selected to treat with omeprazole suspension 2 mg/ml (40 mg every day) for up to 4 days. Gastric aspirates were sampled before and 1-2.5 hours after the drug administration for the pH measurement using an external pH meter. To evaluate the results more accurately, the results were compared with results of a previous study conducted in the same center (Masih Daneshvari Hospital). In the previous study, pH changes were higher in the groups receiving pantoprazole suspension and omeprazole suspension than the intravenous pantoprazole group, while the present study reported that pH changes were close to that of the intravenous pantoprazole group (p = 0.00).

Results: In this study twenty-nine critically ill patients (14 male, 15 female, mean age: 60.41±15.35 years) were followed for the control of the gastric pH.

On each of the 4 trial days, the mean of the gastric pH alteration was +1.48±1.2. The rate of upper gastrointestinal bleeding was 10.34%.

Discussion: Statistical analysis of the results showed no significant differences between 4 groups in terms of the prevalence of ventilator-associated pneumonia (p = 0.97). Based on results of this analysis, gender, risk factors of sepsis and coagulopathy, the presence of coffee ground in the gastric juice sample was related to post-administration gastric pH and all had a direct and significant relationship with post-administration gastric pH. In the previous study, GI bleeding was evident in 3 cases, of which 2 (11.1%) were in the group receiving intravenous pantoprazole solution and 1 (5.6%) was in the omeprazole oral suspension group. In the present study, the rate of GI bleeding was shown only in 3 (10.43%) patients.

Conclusion: this study showed no significant difference between the group studied here and three groups evaluated in the previous study in terms of prevalence of bleeding.