Prophylaxis against acute stress erosions.

Acute gastroduodenal erosions and ulcerations, often with life-threatening gastrointestinal hemorrhage, contribute to high mortality in critically ill patients. Hypersecretion of gastric acid to some degree seems to be necessary. Antacids and recently cimetidine, a histamine H2-receptor antagonist, have been used for prophylaxis against bleeding from these acute "stress" erosions. Review of studies regarding such prophylaxis suggests that either agent may be effective, but massive life-threatening gastrointestinal hemorrhage has not been decreased by this therapy, and, more important, there has not been an increased survival in treated patients. Furthermore, cimetidine is not approved for such use by the FDA. Currently, in critically ill patients there are multiple risk factors for acute "stress" erosions. An intensive antacid regimen may be impractical. Alternatively, cimetidine may be given as an investigational drug. Further studies are needed on the efficacy of antacids and cimetidine in preventing acute "stress" erosion and bleeding, but such studies should be prospective, controlled, double-blind, stratified, and randomized to produce the most useful data.