Critically ill patients are at increased risk of GI hemorrhage secondary to stress-induced mucosal ulceration. Head injury (Cushing ulcers); mechanical ventilation; NSAID use; shock, trauma, and burns (Curling ulcers); coagulopathy; and a history of peptic ulcer disease or portal hypertension are a few of the risk factors.


Management of Ulceration

  • 1. Early endoscopy for upper GI bleeding
  • 2. Endoscopic or surgical intervention for visible bleeding vessel
  • 3. Aggressive acid suppression for diffuse gastritis; empiric therapy for Helicobacter pylori infection
  • 4. Possible surgical intervention for persistent bleeding from gastritis





Content 9


Complications of Injecting Drug Use

  • Local problems—Abscess (Figures 240-2 
    Image not available.

    A 32-year-old woman with type 1 diabetes developed large abscesses all over her body secondary to injection of cocaine and heroin. Her back shows the large scars remaining after the healing of these abscesses. (Courtesy of ­Richard P. Usatine, MD.)

    and 240-3; Abscess), cellulitis, septic thrombophlebitis, local induration, necrotizing fasciitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (e.g., broken needle parts) in local areas.2
    • IDUs are at higher risk of getting methicillin-resistant Staphylococcus aureus(MRSA) skin infections that the patient may think are spider bites (Figure 240-4).
    • Some IDUs give up trying to inject into their veins and put the cocaine directly into the skin. This causes local skin necrosis that produces round atrophic scars (Figure 240-5).
  • IDUs are at risk for contracting systemic infections, including HIV and hepatitis B or hepatitis C.
    • Injecting drug users are at risk of endocarditis, osteomyelitis (Figures 240-6and 240-7), and an abscess of the epidural region. These infections can lead to long hospitalizations for intravenous antibiotics. The endocarditis that occurs in IDUs involves the right-sided heart valves (see Chapter 50, Bacterial Endocarditis).2 They are also at risk of septic emboli to the lungs, group A β-hemolytic streptococcal septicemia, septic arthritis, and candidal and other fungal infections.


Content 3


  • Enteral feedings: method of choice to protect the gastric mucosa
  • Cardiovascular support of visceral perfusion
  • Acid suppression:
    • prophylaxis with H2-blockers (eg, ranitidinefamotidine).
    • Proton-pump inhibitors (eg, lansoprazole, omeprazole) for refractory bleeding or in patients with adverse reaction to histamine blockade.



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