Stress ulcers develop when severe physiological stress damages the gastrointestinal mucosa, particularly in the stomach and duodenum. Stress ulcers can cause upper gastrointestinal bleeding and complicate the management of critical illness, which are also associated with longer intensive care unit stays and poorer outcomes. Variations in prophylactic strategies, drug selection, and treatment duration highlight the need for consistent, evidence-based guidance.
To address this challenge, the CSCCM initiated a multidisciplinary expert panel led by Professor Dechang Chen of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, China. Drawing on a comprehensive review of domestic and international literature, the panel developed the Guidelines for the Prevention and Treatment of Stress Ulcers in Critically Ill Patients (2026). The rigorous formulation process included formulating clinical questions, conducting systematic literature searches and study screening, performing meta-analyses and evidence synthesis, holding iterative peer-review meetings, and securing final approval from the society's standing committee. All recommendations were developed using the GRADE framework. The guidelines were released online on September 28, 2026, and officially published in Volume 6, Issue 6, of the Journal of Intensive Medicine on December 1, 2026.
A total of 23 evidence-based recommendations were developed by the CSCCM for the prevention and management of stress ulcers in critically ill adults. Male sex, coagulopathy, shock, acute coronary syndrome, and higher illness severity scores were identified as factors associated with stress ulcers or bleeding. The panel suggests that close monitoring is also advised for patients receiving renal replacement therapy or medications associated with an increased bleeding risk, including glucocorticoids, anticoagulants, antiplatelet agents, and nonsteroidal anti-inflammatory drugs. For patients with identified risk factors, the guidelines suggest acid-suppressive therapy for stress ulcer prophylaxis, alongside treatment of the underlying illness and stressors. Proton pump inhibitors (PPIs) were suggested in preference to histamine-2 receptor antagonists for prevention. Enteral nutrition was recommended in the absence of contraindications.
For critically ill patients with suspected or confirmed stress ulcers complicated by upper gastrointestinal bleeding, the guidelines strongly recommend PPI therapy on the basis of high-certainty evidence. Routine endoscopy solely to confirm the diagnosis of stress ulcers is not recommended. However, when substantial bleeding persists despite medical management, the panel advises prompt endoscopic evaluation to identify the bleeding source and achieve hemostasis. If endoscopic treatment fails, endovascular or surgical intervention can be considered. The guidelines also address hemodynamic resuscitation targets, red blood cell transfusion, temporary fasting during active bleeding, resumption of nutrition after hemostasis, and discontinuation of medications that may exacerbate bleeding when clinically feasible. These decisions should be individualized according to each patient's clinical status, comorbidities, other illnesses, and response to treatment.
"Preventing stress ulcers requires clinicians to recognize individual risk factors and weigh the benefits of treatment against possible harms," said Prof. Chen.
The guidelines also highlight potential renal adverse events associated with PPI use and suggest monitoring renal function during treatment. However, the strength of the recommendations varied according to the certainty of the evidence. Some questions were addressed using low-quality evidence or good practice statements rather than robust trials conducted specifically in critically ill patients with stress ulcers. These limitations reinforce the need for clinical judgment and individualized care.
Overall, the guidelines provide a common approach to stress ulcer prevention and treatment and may help reduce unwarranted variation in the care of critically ill adults "We hope these recommendations will support consistent, evidence-informed decisions while allowing care to reflect each patient's needs and available resources," Prof. Chen said. A five-year validity period has been assigned to the guidelines, with emerging evidence expected to inform future revisions. Evidence gaps could be addressed through further research involving diverse critically ill populations, while continued evaluation and updates could be supported by collaboration among critical care specialists, statisticians, and evidence-based medicine experts. Their impact on clinical practice and patient outcomes will need to be evaluated as they are implemented.
Reference
Titles of original papers: Guidelines for the prevention and treatment of stress ulcers in critically ill patients (2026)
Journal: Journal of Intensive Medicine
DOI: https://doi.org/10.1016/j.jointm.2026.06.003
About Chinese Society of Critical Care Medicine (CSCCM)
The CSCCM is a premier national academic organization dedicated to advancing the field of intensive care medicine. Operating under the Chinese Medical Association, the society plays a pivotal role in shaping clinical practice, education, and research standards across China. The CSCCM brings together multidisciplinary experts to develop authoritative clinical guidelines, establish standardized training programs, and promote uniform protocols within intensive care units. Through its continuous efforts in professional development and evidence-based medicine, the organization significantly drives clinical homogeneity, improves patient outcomes, and fosters international collaboration in critical care.
About Professor Dechang Chen
Dr. Dechang Chen is a Professor in the Department of Critical Care Medicine at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, China, where he serves as chief physician and doctoral supervisor. He received a Doctor of Clinical Medicine degree from the Second Military Medical University in 2003. His research focuses on basic and clinical aspects of sepsis-induced intestinal injury, the prevention and treatment of gastrointestinal failure in critically ill patients, post-traumatic systemic inflammatory response syndrome, and the diagnosis and management of severe infections and septic shock.
