Pathophysiology of the upper gastrointestinal tract in the critically ill patient: Rationale for the therapeutic benefits of acid suppression
Pathophysiology of the upper gastrointestinal tract in the critically ill patient: Rationale for the therapeutic benefits of acid suppression
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DOI：
10.1097/00003246-200206001-00002
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发表时间：
2002-06-01
影响因子：
8.8
通讯作者：
Fennerty, MB
中科院分区：
文献类型：
--
作者：
Fennerty, MB
胃粘膜损伤发生在重症监护室的危重患者中，并在严重生理应激的情况下发展。在进入重症监护室的24小时内，75%至100%的重症患者表现出与应激相关的粘膜疾病的证据。应激性溃疡存在临床上重要的出血风险，这与生理学改变相关，如低血压或心动过速，或导致贫血或需要输血。临床上重要的出血发生在约1%至4%的危重患者中。应激相关粘膜疾病的病理生理学很复杂。造成应激性溃疡的主要因素是血流减少、粘膜缺血、低灌注和再灌注损伤。酸抑制方案，提高胃内pH值，并保持pH值随着时间的推移，有可能预防应激相关的粘膜疾病。胃内pH研究表明，pH>4可能足以预防应激性溃疡，而pH>6可能是维持消化性溃疡再出血风险患者凝血所必需的。比较静脉内施用组胺-2-受体拮抗剂和质子泵抑制剂升高和维持胃内pH的能力的研究表明，尽管两者都可以将pH升高至>4，但质子泵抑制剂更可能维持该pH。与组胺-2-受体拮抗剂不同，质子泵抑制剂可以升高和维持胃内pH>6。这与重症监护室中止血后有消化性溃疡再出血风险的患者相关。
Gastric mucosal damage occurs in critically ill patients in intensive care units and develops in the setting of severe physiologic stress. Within 24 hrs of admission to the intensive care unit, 75% to 100% of critically ill patients demonstrate evidence of stress-related mucosal disease. Stress ulcers present a risk of clinically important bleeding, which is associated with alterations in physiology, such as hypotension or tachycardia, or results in anemia or the need for transfusion. Clinically important bleeding occurs in approximately 1% to 4% of critically ill patients. The pathophysiology of stress-related mucosal disease is complex. Major factors responsible for stress ulcer are decreased blood flow, mucosal ischemia, and hypoperfusion and reperfusion injury. Acid-suppressive regimens that elevate the intragastric pH and maintain the pH over time have the potential to prevent stress-related mucosal disease. Intragastric pH studies have demonstrated that, whereas a pH of >4 may be adequate to prevent stress ulceration, a pH of >6 may be necessary to maintain clotting in patients at risk of rebleeding from peptic ulcer. Studies comparing the ability of intravenous administrations of histamine-2-receptor antagonists and proton pump inhibitors to raise and maintain intragastric pH suggest that, although both can raise the pH to >4, proton pump inhibitors are much more likely to maintain this pH. Unlike histamine-2-receptor antagonists, proton pump inhibitors can elevate and maintain the intragastric pH at >6. This is relevant for patients in the intensive care unit at risk for rebleeding from peptic ulcers after hemostasis.