Clinical Presentation

Critically ill patients are often asymptomatic in the early stages of stress ulcer development. Endoscopic evidence of mucosal damage is seen in 75-100% of ICU patients within 1-2 days of admission.

Potential signs of stress ulceration and bleeding include:

• Hematemesis (blood or coffee ground material from nasogastric tube)
• Melena
• Occult bleeding (guaiac positive stools)
• Anemia, hypotension or shock
• Risk factors for clinically important bleeding include:
• Mechanical ventilation for >48 hours
• Coagulopathy (thrombocytopenia, elevated INR, prolonged PTT)
• Major trauma or burns
• Head injury
• Sepsis and organ failure
• Chronic liver disease

Bleeding from stress ulcers can range from superficial damage to deep ulcerations, which have higher risks of serious bleeding and mortality. Stress ulcers are often diffuse and not amenable to endoscopic therapy.

Misdiagnosis can occur due to multiple potential causes of gastrointestinal bleeding in critically ill patients. However, patients with risk factors for stress ulceration who develop bleeding should be assumed to have stress-related mucosal damage until proven otherwise.