Management – Overview

The cornerstone of management is prevention of clinically significant bleeding through stress ulcer prophylaxis (SUP) in high-risk patients. General treatment approaches include:

• Occult bleeding – Increased monitoring and optimization of prophylaxis agents. Rarely requires endoscopy or intervention.
• Overt bleeding – Hemodynamic stabilization and treatment guided by endoscopy if a lesion is identified. General treatment principles are similar to peptic ulcer bleeding.
• Prophylaxis – Should be provided to those with strong risk factors for stress ulcer bleeding. Requires regular reassessment for ongoing need.
• Pharmacologic options for prophylaxis include proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), and sucralfate. PPIs or H2RAs are preferred first-line agents.
• Enteral nutrition helps reduce risk of stress ulcer bleeding and should be initiated when feasible.
• Mechanical ventilation settings to reduce aspiration and upright positioning can also help decrease risk.
• Endoscopic therapy is rarely beneficial given diffuse nature of lesions. Definitive treatment is resolution of the underlying critical illness.
• Treatment of complications (perforation, bleeding) depends on severity and may require surgery.

The main goal is to provide effective prophylaxis to those at risk while minimizing adverse effects from unnecessary overuse of acid suppression.