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BACKGROUND: Upper gastrointestinal (GI) bleeding due to stress ulcers contributes to increased morbidity and mortality in people admitted to intensive care units (ICUs). Stress ulceration refers to GI mucosal injury related to the stress of being critically ill. ICU patients with major bleeding as a result of stress ulceration might have mortality rates approaching 48.5% to 65%. However, the incidence of stress-induced GI bleeding in ICUs has decreased, and not all critically ill patients need prophylaxis. Stress ulcer prophylaxis can result in adverse events such as ventilator-associated pneumonia; therefore, it is necessary to evaluate strategies that safely decrease the incidence of GI bleeding. OBJECTIVES: To assess the effect and risk-benefit profile of interventions for preventing upper GI bleeding in people admitted to ICUs. SEARCH METHODS: We searched the following databases up to 23 August 2017, using relevant search terms: MEDLINE; Embase; the Cochrane Central Register of Controlled Trials; Latin American Caribbean Health Sciences Literature; and the Cochrane Upper Gastrointestinal and Pancreatic Disease Group Specialised Register, as published in the Cochrane Library (2017, Issue 8). We searched the reference lists of all included studies and those from relevant systematic reviews and meta-analyses to identify additional studies. We also searched the World Health Organization International Clinical Trials Registry Platform search portal and contacted individual researchers working in this field, as well as organisations and pharmaceutical companies, to identify unpublished and ongoing studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs with participants of any age and gender admitted to ICUs for longer than 48 hours. We excluded studies in which participants were admitted to ICUs primarily for the management of GI bleeding and studies that compared different doses, routes, and regimens of one drug in the same class because we were not interested in intraclass effects of drugs. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures as recommended by Cochrane. MAIN RESULTS: We identified 2292 unique records.We included 129 records reporting on 121 studies, including 12 ongoing studies and two studies awaiting classification.We judged the overall risk of bias of two studies as low. Selection bias was the most relevant risk of bias domain across the included studies, with 78 studies not clearly reporting the method used for random sequence generation. Reporting bias was the domain with least risk of bias, with 12 studies not reporting all outcomes that researchers intended to investigate.Any intervention versus placebo or no prophylaxisIn comparison with placebo, any intervention seems to have a beneficial effect on the occurrence of upper GI bleeding (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.39 to 0.57; moderate certainty of evidence). The use of any intervention reduced the risk of upper GI bleeding by 10% (95% CI -12.0% to -7%). The effect estimate of any intervention versus placebo or no prophylaxis with respect to the occurrence of nosocomial pneumonia, all-cause mortality in the ICU, duration of ICU stay, duration of intubation (all with low certainty of evidence), the number of participants requiring blood transfusions (moderate certainty of evidence), and the units of blood transfused was consistent with benefits and harms. None of the included studies explicitly reported on serious adverse events.Individual interventions versus placebo or no prophylaxisIn comparison with placebo or no prophylaxis, antacids, H2 receptor antagonists, and sucralfate were effective in preventing upper GI bleeding in ICU patients. Researchers found that with H2 receptor antagonists compared with placebo or no prophylaxis, 11% less developed upper GI bleeding (95% CI -0.16 to -0.06; RR 0.50, 95% CI 0.36 to 0.70; 24 studies; 2149 participants; moderate certainty of evidence). Of ICU patients taking antacids versus placebo or no prophylaxis, 9% less developed upper GI bleeding (95% CI -0.17 to -0.00; RR 0.49, 95% CI 0.25 to 0.99; eight studies; 774 participants; low certainty of evidence). Among ICU patients taking sucralfate versus placebo or no prophylaxis, 5% less had upper GI bleeding (95% CI -0.10 to -0.01; RR 0.53, 95% CI 0.32 to 0.88; seven studies; 598 participants; moderate certainty of evidence). The remaining interventions including proton pump inhibitors did not show a significant effect in preventing upper GI bleeding in ICU patients when compared with placebo or no prophylaxis.Regarding the occurrence of nosocomial pneumonia, the effects of H2 receptor antagonists (RR 1.12, 95% CI 0.85 to 1.48; eight studies; 945 participants; low certainty of evidence) and of sucralfate (RR 1.33, 95% CI 0.86 to 2.04; four studies; 450 participants; low certainty of evidence) were consistent with benefits and harms when compared with placebo or no prophylaxis. None of the studies comparing antacids versus placebo or no prophylaxis provided data regarding nosocomial pneumonia.H2 receptor antagonists versus proton pump inhibitorsH2 receptor antagonists and proton pump inhibitors are most commonly used in practice to prevent upper GI bleeding in ICU patients. Proton pump inhibitors significantly more often prevented upper GI bleeding in ICU patients compared with H2 receptor antagonists (RR 2.90, 95% CI 1.83 to 4.58; 18 studies; 1636 participants; low certainty of evidence). When taking H2 receptor antagonists, 4.8% more patients might experience upper GI bleeding (95% CI 2.1% to 9%). Nosocomial pneumonia occurred in similar proportions of participants taking H2 receptor antagonists and participants taking proton pump inhibitors (RR 1.02, 95% CI 0.77 to 1.35; 10 studies; 1256 participants; low certainty of evidence). AUTHORS' CONCLUSIONS: This review shows that antacids, sucralfate, and H2 receptor antagonists might be more effective in preventing upper GI bleeding in ICU patients compared with placebo or no prophylaxis. The effect estimates of any treatment versus no prophylaxis on nosocomial pneumonia were consistent with benefits and harms. Evidence of low certainty suggests that proton pump inhibitors might be more effective than H2 receptor antagonists. Therefore, patient-relevant benefits and especially harms of H2 receptor antagonists compared with proton pump inhibitors need to be assessed by larger, high-quality RCTs to confirm the results of previously conducted, smaller, and older studies.

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BACKGROUND: Little information is available on the effect of dementia on outcomes of elderly patients with hemorrhagic peptic ulcer disease at the population level. AIMS: This study aimed to investigate the effect of dementia on outcomes of elderly patients with hemorrhagic peptic ulcer based on a national administrative database. METHODS: A total of 14,569 elderly patients (≥80 years) who were treated by endoscopic hemostasis for hemorrhagic peptic ulcer were referred to 1073 hospitals between 2010 and 2012 in Japan. We collected patients' data from the administrative database to compare clinical and medical economic outcomes of elderly patients with hemorrhagic peptic ulcers. Patients were divided into two groups according to the presence of dementia: patients with dementia (n = 695) and those without dementia (n = 13,874). RESULTS: There were no significant differences in in-hospital mortality within 30 days and overall mortality between the groups (odds ratio; OR 1.00, 95 % confidence interval; CI 0.68-1.46, p = 0.986 and OR 1.02, 95 % CI 0.74-1.41, p = 0.877). However, the length of stay (LOS) and medical costs during hospitalization were significantly higher in patients with dementia compared with those without dementia. The unstandardized coefficient for LOS was 3.12 days (95 % CI 1.58-4.67 days, p < 0.001), whereas that for medical costs was 1171.7 US dollars (95 % CI 533.8-1809.5 US dollars, p < 0.001). CONCLUSIONS: Length of stay and medical costs during hospitalization are significantly increased in elderly patients with dementia undergoing endoscopic hemostasis for hemorrhagic peptic ulcer disease.

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The article discusses changes in the psychological status and the forming of various types of attitude towards the disease in patients with a favorable and unfavorable course of peptic ulcer (PU). The subjects of the study were 82 patients with exacerbation of PU; among them there were 30 patients with a favorable and 52 patient with a complicated course. Patients with a favorable course of PU did not displayed prominent peaks in SMOL profile, which reflected a relatively benign state of their psychological status. Favorable type of response to the disease--harmonic and anosognostic--with lesser social disadaptation prevailed in these patients. On the contrary, patients with a complicated course of PU displayed a relative increase in the profile on the scales, reflecting a higher tension in combination with diadaptive response to the disesase, which should be taking into account when correcting treatment.

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In spite of achievements of modern pharmacology, duodenal ulcer (DU) incidence and, what is more, the frequency of complications, are still high. The presented study was carried out in order to evaluate somatic, personal, and psychological peculiarities of patients receiving different types of treatment for duodenal ulcers complicated by hemorrhage or perforation. The patients whose treatment for perforation or hemorrhage was not radical, demonstrated high relapse rate within 4 to 7 years after hospitalization (76% and 50%, respectively). Study of coping revealed high rate of "optimization " mechanism in the emotional sphere of the patients in both groups (56% in the group with perforation, 48%--in the group with hemorrhage). The dominance of this coping mechanism was associated with frequent refusals to receive repeated courses of antiulcer therapy. The study found significant difference in the cognitive and behavioral spheres of coping between the groups. So, "active avoidance" and "retreat" mechanisms predominated in the behavior of hemorrhage patients, which was accompanied by significant reduction in a range of life quality parameters. The obtained data correspond to the results of study of "internal picture" of the disease. Anosognostic attitude to the disease was predominant in perforation group (43.5%), while ergopathic attitude was typical of hemorrhage patients (28.6%). The results suggest that in order to increase the life quality and compliance of patients with DU, medical and rehabilitation measures should be individualized and optimized in accordance with personal and psychological peculiarities of these patients.

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BACKGROUND/AIMS: The pathogenesis of acute stress-related hemorrhage in critically ill polytraumatized patients is uncertain and any role of Helicobacter pylori infection is unknown. The aim of our study was to evaluate the relationship between Helicobacter pylori serological status of patients developing stress-related bleeding and those with no appearance of upper gastrointestinal bleeding. METHODOLOGY: In our single-center prospective cohort study we investigated over a 3-year period all consecutive patients with upper gastrointestinal hemorrhage for Helicobacter pylori infection by serology. Control group comprised 101 such patients with no evidence of hemorrhage. RESULTS: Of 396 assessable patients, stress-related upper gastrointestinal bleeding was observed in 11 (3.1%) patients. Six (55%) of the 11 bleeding patients and 45 (45%) of the 101 control group patients had serological evidence of Helicobacter pylori infection (p=0.5). Bleeding developed significantly more often in patients with more serious injury (for ISS, p=0.04, for TRISS p=0.03). Bleeding patients showed insignificantly higher mortality (36% vs. 15%; p=0.09). CONCLUSIONS: Helicobacter pylori infection was not significantly more prevalent in polytraumatized patients with hemorrhage when compared with control group. Our data suggest that the infection with Helicobacter pylori does not play an important role in bleeding, indicating no causative role for it in upper gastrointestinal hemorrhage of polytraumatized patients. The incidence of bleeding is low and bleeding develops usually later, in the meantime is the Helicobacter pylori infection eradicated with the antibiotics used for another purpose.

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Patients admitted to intensive care units frequently develop stress ulcers, erosive gastritis and complications such as upper gastrointestinal bleeding. Stress-related upper gastrointestinal bleeding (UGIB) has been of particular concern to many practitioners working in intensive care units and has led to the treatment of most if not all patients admitted to these units with antacids, H2 receptor antagonists or sucralfate in order to protect the gastric mucosa. It is considered that the 3 aforementioned medications are effective in decreasing the overall incidence of UGIB, but it has not been demonstrated that they are efficacious in reducing the incidence of clinically significant UGIB, ie cases that are complicated by anemia, hemorrhagic shock, or death. In addition, the cost and complications resulting from prophylaxis should be taken into consideration, which raises further questions about the systematic use of these agents. This article reviews the current literature on this subject; the authors propose a conservative use of prophylaxis, and that these agents be prescribed in a selective manner to the patients at the greatest risk of developing UGIB.

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A series of studies investigated the role of the amygdala, and its connections with hypothalamic areas, in gastric pathology induced by immobilization. Results showed that lesions in the medial amygdala and the ventral amygdalofugal pathway reduced the stomach pathology induced by restraint. Lesions in the stria terminalis, on the other hand, increased the severity of stomach pathology. It is concluded that the lesions in the medial nuclei and the ventral pathway attenuated the effectiveness of the noxious stimulus to produce gastrointestinal abnormalities whereas the lesions in the stria terminalis interfered with inhibitory effects.

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