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A previously-healthy 24-year-old male is admitted to the intensive care unit following a motorcycle crash. He sustained head trauma requiring an emergency craniotomy, has burns over 30% of his body, and a fractured humerus. His pain is managed with a continuous fentanyl infusion. Two days after admission to the ICU he develops severe hematemesis. What is the mechanism underlying the development of his hematemesis?
Gastric mucosal disruption
Increased gastric acid production
Helicobacter pylori infection
Answers 1 and 2
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This patient has hematemesis from gastritis secondary to gastric mucosal disruption and increased gastric acid production.
Critically ill patients often have several risk factors for gastritis. Patients with burns often have significant fluid shifts with loss of plasma volume; this loss of volume can lead to sloughing of the gastric mucosa. Additionally, patients with elevated intracranial pressure are thought to have increased vagal tone, which leads to increased gastric acid production. The combination of gastric mucosal disruption and increased gastric acid production increases the chances of gastritis and gastrointestinal bleeding.
Wilkins et al. discuss the diagnosis and management of upper gastrointestinal bleeding. They note that upper gastrointestinal bleeding has been associated with NSAID use as well as Helicobacter pylori infection. The primary management involves resuscitation in patients with severe bleeding and early upper endoscopy, both to confirm diagnosis and to allow for targeted endoscopic treatment.
Alhazzani et al. conducted a systematic review to determine the relative efficacy of proton pump inhibitors compared with histamine 2 receptor antagonists in preventing gastrointestinal bleeding in ICU patients. They noted that in 14 trials (total of 1720 patients), proton pump inhibitors were more effective than histamine 2 receptor antagonists at reducing upper gastrointestinal bleeding (relative risk = 0.35), but there was no difference in the risk of hospital acquired pneumonia, mortality, or length of stay.
Illustration A is an image of a gastric ulcer with a clot on the surface.
Illustration B is a diagram of the management of an acute upper gastrointestinal bleed.
Answers 1 & 2: This patient has reason for both gastric mucosal disruption AND increased gastric acid production, not just one.
Answers 3: While Helicobacter pylori infection is associated with gastritis and hematemesis, in this previously healthy and young critically ill patient with head trauma and extensive burns, gastric mucosal disruption and overproduction of acid are more likely explanations.
Answer 5: Fentanyl over use is not associated with gastritis.
Wilkins T, Khan N, Nabh A, Schade RR.
Am Fam Physician. 2012 Mar 01;85(5):469-76. PMID: 22534226 (Link to Abstract)
Alhazzani W, Alenezi F, Jaeschke RZ, Moayyedi P, Cook DJ.
Crit Care Med. 2013 Mar;41(3):693-705. PMID: 23318494 (Link to Abstract)
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PUD vs. Gastritis