Key messages

• The incidence of gastrointestinal bleeding from stress ulceration in critically ill patients has decreased over the last decade.

• Patients at highest risk of bleeding are those who have been mechanically ventilated for 48 h or more and those with a coagulopathy (risk approximately 4 per cent).

• Other critically ill patients have a very low risk of bleeding, and so it may be reasonable to withhold stress ulcer prophylaxis (risk less than 0.01 per cent).

• Antacids, H2-receptor antagonists, and sucralfate all appear to decrease the rate of bleeding.

• Sucralfate is associated with a lower rate of nosocomial pneumonia than drugs that increase gastric pH.

• No stress ulcer prophylactic agent has been shown definitively to reduce mortality in critically ill patients.

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