Preventing Upper Gastrointestinal Bleeding in Hospitalized Patients: What Patients Need to Know

Table of Contents

• Introduction: Why This Matters for Hospitalized Patients
• Understanding Different Types of Gastrointestinal Bleeding
• How Stress Affects Your Stomach During Illness
• How Common Is Hospital-Acquired Bleeding?
• Who Is Most at Risk for Bleeding Complications?
• What Bleeding Means for Recovery and Survival
• Medications Used to Prevent Bleeding
• The Benefits of Acid-Suppressing Medications
• Potential Risks and Side Effects of Prevention
• Current Recommendations and Future Directions
• What This Research Doesn't Tell Us
• Source Information

Introduction: Why This Matters for Hospitalized Patients

For approximately forty years, doctors have prescribed acid-suppressing medications to prevent upper gastrointestinal bleeding in seriously ill hospitalized patients. These medications are given to 80-90% of critically ill patients in intensive care units (ICUs) worldwide. However, recent research has begun to question whether the benefits of these medications always outweigh the potential risks.

This article explains what upper gastrointestinal bleeding is, who is at risk, how doctors try to prevent it, and what the latest research says about the best approaches to protection. Understanding these issues can help patients and families have more informed discussions with their healthcare teams about prevention strategies during hospitalization.

Understanding Different Types of Gastrointestinal Bleeding

Upper gastrointestinal bleeding refers to bleeding that occurs in the esophagus (the tube connecting your mouth to your stomach), stomach, or duodenum (the first part of the small intestine). Doctors classify this bleeding into two main types:

• Primary bleeding: Bleeding that is the main reason for hospital admission
• Secondary bleeding: Bleeding that develops during hospitalization for other medical problems

Patients who develop bleeding during hospitalization (secondary bleeding) tend to be older, sicker, and more likely to have other health conditions such as heart disease, lung disease, or chronic kidney failure compared to patients admitted specifically for bleeding issues.

Most prevention efforts focus on stopping secondary bleeding before it starts, either in patients with a history of gastrointestinal problems or in those who might develop new stomach issues due to the stress of hospitalization.

How Stress Affects Your Stomach During Illness

Your stomach normally produces strong acid (with a pH of approximately 2) to help digest food and kill harmful bacteria. Despite this acidic environment, your stomach has several built-in protection systems:

• A protective mucus layer that coats the stomach lining
• Prostaglandins and nitric oxide that help maintain this protective barrier
• Good blood flow that brings oxygen and bicarbonate to neutralize acid
• Acid sensors that reduce acid production when pH drops too low

During serious illness, these protective systems can break down. Inflammation, poor blood flow to the digestive system, low blood volume, shock, or low cardiac output can damage the stomach's lining. This damage, combined with ongoing acid production, can lead to erosions (superficial damage) or ulcers (deeper sores) that may bleed.

While acid is often blamed for these problems, research suggests that the breakdown of the stomach's protective barrier may be more important than acid itself in causing bleeding during critical illness.

How Common Is Hospital-Acquired Bleeding?

The frequency of gastrointestinal bleeding in hospitalized patients varies significantly depending on how sick they are and what preventive measures they receive:

Historical data (50 years ago): Studies from the 1970s found that 75-100% of critically ill, injured, or burned patients showed stomach damage during endoscopy procedures. At that time, 15-50% of critically ill patients had hidden (occult) bleeding, while 5-25% had visible bleeding if they weren't receiving prevention medication.

Current data in ICU patients: A large 2015 international study of 1,034 diverse ICU patients found that 4.7% (49 patients) had visible bleeding. However, only 2.8% (29 patients) had what doctors consider "clinically important" bleeding - bleeding serious enough to require blood transfusions or other interventions.

Certain high-risk groups have much higher rates. Patients with bleeding disorders or those receiving extracorporeal life support (advanced life support machines) had bleeding rates of 13.6% in one study of 132 patients.

Non-ICU hospital patients: Bleeding is much less common in patients on regular hospital wards. Studies show rates ranging from 0.005% to 0.4% in general medical patients. However, specific high-risk groups, such as patients with acute kidney injury, may have rates as high as 7.8%.

Who Is Most at Risk for Bleeding Complications?

Research has identified several factors that significantly increase a patient's risk of developing gastrointestinal bleeding during hospitalization:

Major risk factors for ICU patients:

• Mechanical ventilation for 48 hours or longer (15.6 times higher risk)
• Coagulopathy (blood clotting problems) (4.5 times higher risk)
• Three or more coexisting diseases (8.9 times higher risk)
• Liver disease (7.6 times higher risk)
• Renal replacement therapy (dialysis) (6.9 times higher risk)
• Acute coagulopathy (4.2 times higher risk)
• High organ failure scores (1.4 times higher risk for each point increase)

Other significant risk factors include neurologic injuries (such as traumatic brain injury) combined with severe physiological stress, extracorporeal life support, and certain medications like acid suppressants (which may be prescribed because patients are already at high risk).

Risk factors for non-ICU patients:

• Age over 60 years
• Male sex
• Liver disease
• Acute renal failure
• Sepsis (serious bloodstream infection)
• Treatment by medical (rather than surgical) services
• Prophylactic anticoagulation (blood thinners)
• Coagulopathy with or without antiplatelet agents
• Anticoagulant therapy
• Clopidogrel medication

Researchers have identified that approximately 13% of hospitalized patients fall into a high-risk category where the potential benefit of prevention medication might be greatest.

What Bleeding Means for Recovery and Survival

Gastrointestinal bleeding during hospitalization can significantly impact patient outcomes:

For ICU patients: Clinically important bleeding is associated with 4-8 additional days in the ICU and may increase the risk of death. One study found that bleeding was associated with a 70% increased risk of mortality within 90 days, though this result wasn't statistically definitive (odds ratio 1.7; 95% confidence interval 0.7 to 4.3). For patients on extracorporeal life support, gastrointestinal bleeding was associated with nearly 6 times higher risk of dying in the hospital.

For non-ICU patients: The impact of bleeding depends on the patient's underlying illnesses and the amount of blood loss. Shock, sepsis, renal failure, and cirrhosis are associated with increased risk of death in patients who experience bleeding during hospitalization.

Medications Used to Prevent Bleeding

Doctors use two main types of acid-suppressing medications to prevent stress-related bleeding:

1. Histamine H2-receptor antagonists: These were the most commonly used drugs for many years. They reduce acid production by blocking histamine receptors in the stomach.
2. Proton-pump inhibitors (PPIs): These are now the most frequently prescribed medications for bleeding prevention. They work by more completely blocking acid production.

Another approach is enteral nutrition (feeding through a tube into the stomach or intestine). Food in the stomach can buffer acid, stimulate prostaglandin production, and improve blood flow to the stomach lining. Some research suggests that early feeding might increase gastric pH more effectively than acid suppression and might theoretically reduce bleeding risk while also preventing hospital-acquired malnutrition.

The Benefits of Acid-Suppressing Medications

A comprehensive analysis of 57 clinical trials involving thousands of patients provides the best evidence about the effectiveness of different prevention strategies:

Proton-pump inhibitors vs. H2-receptor antagonists: PPIs reduce bleeding risk by 60% (odds ratio 0.4; 95% CI 0.2 to 0.7)

Proton-pump inhibitors vs. no treatment/placebo: PPIs reduce bleeding risk by 80% (odds ratio 0.2; 95% CI 0.1 to 0.6)

Proton-pump inhibitors vs. sucralfate: PPIs reduce bleeding risk by 70% (odds ratio 0.3; 95% CI 0.1 to 0.7)

This analysis of 31 trials involving 5,283 patients provides moderate-quality evidence that proton-pump inhibitors are the most effective medication for preventing clinically important gastrointestinal bleeding. Importantly, none of the prevention options showed significant differences in overall mortality risk based on data from 36 trials with 5,498 patients.

Potential Risks and Side Effects of Prevention

There is growing concern that acid-suppressing medications might increase the risk of hospital-acquired infections, particularly pneumonia:

Mechanism: Stomach acid helps protect against harmful bacteria. Reducing acid may change the gut microbiome (the collection of bacteria in your digestive system) and allow dangerous bacteria to grow, which could then be inhaled into the lungs.

Evidence for increased pneumonia risk: The network analysis found moderate-quality evidence that both proton-pump inhibitors and H2-receptor antagonists may increase pneumonia risk compared to no treatment, though the confidence intervals were wide.

Additional studies support this concern:

• In 35,312 mechanically ventilated patients, those receiving PPIs had a 20% increased risk of ventilator-associated pneumonia (odds ratio 1.2; 95% CI 1.03 to 1.41)
• In 21,214 cardiac surgery patients, PPIs increased the risk of nosocomial pneumonia by 19% compared to H2-receptor antagonists (risk ratio 1.19; 95% CI 1.03 to 1.38)

These infections are concerning because they are more common than bleeding events and are associated with higher morbidity, mortality, and healthcare costs.

Current Recommendations and Future Directions

Based on the current evidence, researchers suggest a more thoughtful approach to bleeding prevention:

For high-risk ICU patients: Those with mechanical ventilation for ≥48 hours or coagulopathy likely benefit from prophylaxis, with proton-pump inhibitors appearing most effective.

For lower-risk patients: The benefits of routine acid suppression are less clear, and the potential risks of pneumonia may outweigh the benefits.

Enteral nutrition: Early feeding through tubes may provide protection against bleeding while avoiding the infection risks associated with acid suppression. However, this approach hasn't been directly compared to medication in clinical trials.

Future research needs: Studies should focus on better identifying which patients truly benefit from prevention, comparing enteral nutrition directly with acid suppression, and developing more targeted approaches that maximize benefits while minimizing risks.

What This Research Doesn't Tell Us

While this review provides comprehensive information, several important limitations remain:

• Most studies compared different prevention strategies rather than comparing prevention to no treatment
• There's limited direct evidence about the benefits of enteral nutrition specifically for bleeding prevention
• The exact balance of benefits and harms may differ for specific patient subgroups
• Long-term outcomes beyond the hospital stay aren't well studied
• More research is needed on how to best identify patients who will benefit most from prevention

These limitations mean that doctors must individualize decisions about bleeding prevention based on each patient's specific risk factors and clinical situation.

Source Information

Original Article Title: Prophylaxis against Upper Gastrointestinal Bleeding in Hospitalized Patients

Authors: Deborah Cook, M.D., and Gordon Guyatt, M.D.

Publication: The New England Journal of Medicine, June 28, 2018

DOI: 10.1056/NEJMra1605507

This patient-friendly article is based on peer-reviewed research from The New England Journal of Medicine. It maintains all original data, statistics, and findings while translating the technical medical information into accessible language for patients and families.