Gastroenterology

HOW TO MANAGE PATIENTS WITH ACUTE

STRESS ULCER ?
NASRUL ZUBIR
SUBBAGIAN GASTROENTERO-HEPATOLOGI BAGIAN ILMU
PENYAKIT DALAM
FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS PADANG
Stress –related mucosal disease (SRMD): Gastroenterology

•Is significant cause of morbidity and mortality in critically ill

patients in ICU

•Because upper gastrointestinal bleeding is often an indicator

of poor patient

•Evaluated the incidence of bleeding in ICU 48.5% mortality rate

compared 9.1% for other patient ( p< 0.001)

•In increase mortality can also lead to prolonged length of

hospital stay. ( 4 days-8 days )

( Cook, et al, 1994; Harris ,et al, 2014 )

 Gastroenterology

•Synonym:
–Stress ulcer
–Stress erosion
–Diffuse mucosal injury
–Acute erosive gastritis

Lucus CE et. al. Arch Surg. 1971 ; 102: 266-273

Effects of stressor
Gastroenterology

Gut
motility
Paracelluler
permeability

Secretion
Gut
Stress microbiota

Viseral
sensitivity Mucosal
blood flow
Stress – related mucosal disease (SRMD): Gastroenterology

SRMD

Stress
related injury Stress Ulcer
(SRI)

Superfisial Deep

Diffuse Focal
What Causes Stress Ulcer ? Gastroenterology

• Ischemia , impaired mucosal blood flow

• Acid
• Free Radical
• Thyrotropin releasing hormone (TRH)
• Prostaglandin
• Glucose
• Angiotensin II
• Nicotine
• Bile salt
Gastroenterology
Gastroenterology
Diagnosis SRMD Gastroenterology

• Gambaran klinis
• Hubungan dengan stresor ( Psikis ,Fisis )
• Komplikasi perdarahan SCBA
• Endoskopi SCBA
Reduction in Mucosal Protection
Gastroenterology

•Decreased Synthesis of mucosal protaglandin

•Impared epithelial repair
•Oxygen radical
•Bile refluxate
•Disruption of celluler mechanisms
•Dysfunction in mucosa production
•Alteration of UGI motility
•Impared bicarbonate secretion
Gastroenterology
Gastroenterology
 Risk Factors for Stress Ulcer ?
Gastroenterology

• Respiratory failure requiring mechanical ventilation

• Coagulopathy
• Shock
• Severe sepsis
• Head trauma
• Neurosurgery
• Severe burn
• Tetraplegia
• Multiple organ failure

Tryba M et al. Drugs. 1997:54:581-596

Gastroenterology
Treatment of stress ulcer bleeding
Gastroenterology

• 1 Medical therapy :
 Initial therapy

 Medications

 Proton pump inhibitors (PPI),Prosogan

 Intravenous PPI

PPI 80 mg bolus , 8 mg/jam ,2-3 days

 Octreotide

• Endoscopy therapy……
2. Endoscopy therapy Gastroenterology

1. Hemostatic technique are equally effective

with adrenaline injection dilute (1 : 10.000)
2. Thermal haemostatis ,argon plasma
coagulation (APC)
3. Bipolar electrocoagulation (BPE)
4. Endoclip ( hemoclip )
5. Endoscopic band ligation
6. Powder hemospray
Drugs Used to Manage Stress Related Mucosal
Damage Gastroenterology

• Antacids
• Sucralfate
• Histamine-2 receptor antagonists (H2RAS)
• Proton pump inhibitors (PPIs)
Gastroenterology
 Mengapa perlu mencapai pH>4?
Gastroenterology

• Inaktivasi pepsin meningkat secara dramatis pada titik

kritis pH 42

1. Berstad A. Scand J Gastroenterol 1970; 5(5): 343–8. 2. Vorder Bruegge WF et al. J Clin Gastroenterol 1990; 12 (Suppl 2): S35–40.
The Power of LANSOPRAZOLE INJ :
Gastroenterology

1
Fast onset to reach the first critical point pH>4.
• Prosogan® INJ provides fast onset of acid suppression exceeds the critical
point pH>4.1
• Acid suppression occurred during the first hour administration of Prosogan®
INJ 30 mg either through 2 minutes bolus injection or 30 minutes infusion.1
• Prosogan® INJ fast onset to reaches pH> 4 to help blood clot and recovery,
providing the power to control gastric pH in critical patient.1

Sustain intragastric pH>6.2

• The therapeutic goal in GI bleeding patients is to achieve an intragastric
pH > 6.0, a point at which the clotting process is optimized and any
formed clot is stabilized.2
• Lansoprazole INJ sustain intragastric pH> 6 to improve recovery and reduce
re-bleeding
References : 1. Metz DC et al. Pharmacotherapy 2008; 28 (3); 301-7. 2. Metz DC et al. Aliment Pharmacol Ther 23, 985–995
 Safety and Efficacy of Lansoprazole Injection in Upper GI
Bleeding : a Postmarketing Surveillance Conducted in Indonesia Gastroenterology

Ari F. Syam, Arini Setiawati Acta Med Indones-Indones J Intern Med 2013
Unique & advantage of FDT Formulation
Gastroenterology

Lansoprazole FDT with multiple layers preserve maximum activity

7 layers with a specific purpose :

1. Inert Core
2. Lansoprazole layer
3. Under-coating layer 
improves stability in high humidity
4. 1st enteric-coating layer 
improves stability of lansoprazole
5. 2nd enteric-coating layer 
prevents breakage of the enteric coats
during tablet compression
6. 3rd enteric-coating layer 
neutralizes taste of microgranule
7. Over-coating layer 
improves tablet hardness

Lansoprazole FDT is the first PPI with innovative

formulation : Fast Disintegrating tablet
Designed to provide your patients with convenience
Baldi F, Malfertheiner P. Digestion 2003;67:1-5.
 Pantoprazole has a low potential to interact
with other medications Gastroenterology

Comperative analysis of PPI pharmacokinetic drug interactions

Wedemeyer RS, Blume H. Drug Saf 2014; 37:201-11.

Pantoprazole has a low potential to interact
with other medications Gastroenterology

Table adapted from Blume et al.1 and Wedemeyer et al.2

Pantoprazole, lansoprazole and rabeprazole appear to be associated with lower incidences of

DDIs than omeprazole and esomeprazole However, only the interaction profile of
pantoprazole has been well characterised1
1. Wedemeyer RS, Blume H. Drug Saf 2014; 37:201-11. 2. Blume H, et al. Drug Saf 2006; 29(9): 769-84
Pantoprazole is an effective and tolerable PPI Gastroenterology

Pantoprazole has demonstrated its tolerability and efficacy in a number of

clinical trials

Provide patients an effective & tolerable PPI that designed to improve quality
of life patients
Bosseckert H, et al. Clin Drug Invest 2000 Feb; 19 (2) 103-9
KESIMPULAN Gastroenterology

1. STRESS ULCER SERING TERJADI PADA PASIEN2 YANG DIRAWAT DI ICU

( CRITICAL ILL) YANG MEMPUNYAI ANGKA MORTALITAS YANG TINGGI
DIBANDING DENGAN PASIEN ICU LAINNYA.

2. DIAGNOSIS DITEGAKKAN BERDASARKAN GAMBARAN KLINIS DAN

ENDODKOPI

3. PEMBERIAN TERAPI DENGAN PROTON PUMP INHIBITOR INTRAVENA

( PANTOPRAZOL ) AKAN MEMPERBAIKI KEADAAN SECARA
BERMAKNA
 Gastroenterology

• thank you