Factors and outcomes of stress ulcer related gastrointestinal bleeding in various intensive care units: a retrospective cohort study

doi:10.21203/rs.3.rs-1963517/v1

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Factors and outcomes of stress ulcer related gastrointestinal bleeding in various intensive care units: a retrospective cohort study

https://doi.org/10.21203/rs.3.rs-1963517/v1

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Objective

The purpose of this study is to evaluate the differences of risk factors and outcomes between stress ulcer (SU) patients from neurocritical care unit (NCU) and those from general intensive care unit (GICU).

Methods

The study included consecutive SU patients admitted in our hospital from January 1, 2016 to January 1, 2020. Clinically important stress-related gastrointestinal bleeding (CIB) and death at discharge were chosen as primary endpoints. Pearson Chi-Square test, or Mann-Whitney U test were used to compare the differences of corresponding variables between groups, and multiple logistic regression modals were performed to detect risk factors of primary endpoint events.

Results

A total of 261 eligible SU patients (149 from NCU group and 112 from GICU group) were enrolled, with 88 (33.7%) women and a median age of 65(53–76) years. 136 (52.1%) SU patients experienced CIB, with 68 cases in each group. Compared with the SU patients from GICU, the patients from NCU were older and had a higher proportion of hypertension and previous stroke (all P < 0.05), but a lower rate of coronary heart disease, previous peptic ulcer disease, administration of glucocorticoids or the equivalent, hepatic failure, renal failure, and coagulopathy (all P < 0.05). Similarly, the CIB patients from NCU group had a higher rate of previous stroke, but a lower rate of coronary heart disease, administration of glucocorticoids or the equivalent, renal failure, and coagulopathy, compared with those CIB patients from GICU group (all P < 0.05). A significantly lower mortality was observed in SU patients from NCU group than those from GICU group (16.2% versus 29.7%, P = 0.009), while there was no significant difference for death of CIB patients between NCU group and GICU group (30.9% versus 41.8%, P = 0.188). Four independent risk factors of death, including administration of glucocorticoids or the equivalent, with an odds ratio (OR) of 2.439 and 95% confidence intervals (CIs), 1.131 to 5.259, blood transfusion (OR = 3.329, 95%CI, 1.558–7.112), respiratory failure (OR = 3.405, 95%CI,1.610–7.198), and CIB (OR = 3.793, 95%CI, 1.529–9.414) were identified in the multiple logistic regression modal. The use of nasogastric tube (OR = 5.209, 95%CI, 2.820–9.620), respiratory failure (OR = 3.672, 95%CI, 1.620–8.325) and international standardized ratio＞1.5 (OR = 2.119, 95CI, 1.023–4.389) were associated with a greater risk of CIB, while SU prophylaxis with proton pump inhibitors (OR = 0.277;95%CI, 0.100-0.768) served as the only protective factor for CIB.

Conclusion

CIB was a serious complication that increased the risk of death similarly for critically ill patients both from NCU and GICU, and SU prophylaxis could help to decrease CIBs. The use of nasogastric tube, respiratory failure and INR＞1.5 were associated with a higher risk of CIB.

stress ulcer

gastrointestinal bleeding

outcome

complication

risk factor

Stress Ulcer (SU) is one of the most common gastrointestinal complications for critically ill patients, and clinically important stress-related gastrointestinal bleeding (CIB) after SU serves as an important cause of poor prognosis for these patients. In these critically ill patients, the incidence of SU-related CIB events was about 0.9%-3.5%[1–3], and the risk of CIBs could be as high as 68% in patients who were not treated with preventive drugs (such as Proton Pump Inhibitors, PPIs or Histamine-2 receptor blockers, H2RBs)[4]. At present, the mechanism of SU is still not very clear. It is believed that SU is probably a neuroendocrine stress reaction induced in critically ill patients, in which the brain plays an important role[5]. Intracranial lesions (i.e., brain tumors, stroke, infection, etc.) combined with severe physiologic stress stimulated parasympathetic centers of the hypothalamus and the vagal nuclei in the medulla to increase vagal nerve activity, where the parasympathetic stimulation led to abnormal amounts of acid secretion and consequently gastric ulcers and then bleedings [5]. Morphologically, however, these ulcers after neurologic injury in neurocritical care (NCU) patients were different from the ones that occur after other disease from general intensive care unit (GICU) patients (like shock, trauma and sepsis)[6]. Therefore, SU caused by various primary diseases might have significant differences in risk factors and outcomes. Moreover, the symptoms of SU in critically ill patients from NCU were more likely to be underestimated than those patients from GICU. Therefore, there could be significantly differences in risk factors, and clinical outcomes between CIBs in NCU and GICU patients. However, within each category, most studies with an emphasis on SU from GICU patients were prioritized, but SU from NCU patients were also included to analysis particularly when the sample data were sparse. The purpose of this study was to compare the clinical data of SU patients from NCU group and GICU group, to distinguish the risk factors and outcomes between these two groups, and to provide evidence for their exclusive prophylaxis and treatment.

2.1 Explanatory and outcome variables

Consecutive adult patients more than 18 years with "stress ulcer (SU)" admitted in NCU or GICU from January 1, 2016 to January 1, 2020 in our hospital were retrospectively enrolled, in which all data collected on a standard case report form (CRF). The detailed inclusion process for 96 cases of SU after stroke from NCU was mentioned in our previous study[7], and other SU cases during the study period were collected using the same inclusion criteria. If the data for CRFs were incomplete in medical records, one of the authors would make telephone follow-up (Huang Qiang and Sun Jinmei) or supplement them through outpatient follow-up (Han Yanfei or Zhang Yongbo). Patients were ineligible if they discharged or died within 24h after admission or when the CRFs were still incomplete after all efforts on follow-up.

SU was diagnosed using International Classification of Tenth Revision -Clinical Modification (ICD-10-CM) codes. According to the severity of SU, it could be further divided into clinically important stress-related gastrointestinal bleeding (CIB) and Non-CIB, in which CIB was defined as the SU patients with overt bleeding (e.g., hematemesis, melena, coffee ground nasogastric aspirate, etc.) plus any one of the following within 24h: a spontaneous decline > 20 mmHg in systolic blood pressure or > 10 mmHg measured on sitting up, an increase in heart rate by > 20 bpm, a decrease in hemoglobin by > 2 g/dL and subsequent blood transfusion, intravenous vasoconstrictive drugs and/or invasive hemostatic surgery [1]. According to the primary diagnosis of SU events, it could also be classified as SUs of intracranial lesions (i.e., brain tumors, stroke, infection, etc.) from NCU patients (group NCU) and SUs from other diseases (like shock, trauma, acute myocardial infarction and sepsis, etc.) in GICU patients (group GICU).

Clinical endpoints included death at discharge and CIB events. Variables reported in the analysis included age, sex, primary diagnosis (admitting diagnosis), length of stay, time interval between SU and primary diagnosis (using the date of primary diagnosis as a reference), risk factors of cerebrovascular diseases (hypertension, diabetes, hyperlipidemia, coronary heart disease, atrial fibrillation, previous stroke, smoking and alcoholism), previous peptic ulcer disease, coagulation function and coagulopathy [a platelet count ＜50000 per cubic millimeter, a partial coagulation time (APTT)＞2.0 times the control value or international standardized ratio (INR) of＞1.5], blood glucose indicators (fasting blood glucose, glycated albumin and glycated hemoglobin), renal failure (a creatinine clearance rate lower than 40ml per minute), hepatic failure (any two of the followings: a serum bilirubin concentration more than 150 umol per liter, a serum aspartate aminotransferase level higher than 500 U per liter, a serum albumin level lower than 41g per liter, and clinical manifestations of hepatic coma), administration of glucocorticoids (＞200mg of hydrocortisone or the equivalent) or another nonsteroidal anti-inflammatory drug per day, administration of antiplatelet agents or anticoagulants, pulmonary infection, respiratory failure (a need for mechanical ventilation for at least 48h), the use of nasogastric tube, administration of intravenous vasoconstrictive drugs, the use of invasive hemostatic surgery (underwent endoscopy) and SU prophylaxis (defined as the administration of two or more doses of PPIs or H2RBs [1]). It should be noted that for the indicators that could be repeatedly detected, such as platelet count, APTT, INR, blood glucose indicators, serum aspartate aminotransferase level, and so on, the latest records from the SU event were adopted.

2.3 Statistical analysis

In this study, IBM SPSS Statistics.19.0 software was used for all the statistical calculations, with a two-tailed P value < 0.05 defined as statistically significant. Kruskal-Wallis test was used to detect the normality of the sample. If the sample belonged to non-normal distribution, the continuous variables were presented as median and quartile (P25, P75), the continuous variables with normal distribution were presented as mean and Standard Deviation (SD), and the classified variables were presented as percentage (%). Comparative analysis between two groups were conducted with Mann-Whitney U or Pearson Chi-Square tests for corresponding variables. Multiple logistic regression modals with the variables of P ≤ 0.10 in univariate analysis were performed to estimate odds ratios (ORs) with 95% confidence intervals (CIs) to determine predictors of clinical endpoints (in-hospital mortality and CIBs).

During the study period (January 1, 2016 to January 1, 2020), of the 283 SU patients admitted to NCU or GICU, 7.4% cases (21/283, 12 from NCU and 9 from GICU) were ineligible. Among these 261 SU patients, 149 (57.1%) were from NCU group and 112 (42.9%) were from GICU group. There were 88 (33.7%) women, with a median age of 65(53–76) years. The average time interval between SU and primary diagnosis was 2(1–5) days. Of the 261 SU cases, 136 (52.1%) met the criteria of CIB, in which the incidence of CIB was 45.6% (68/149) in NCU group and 60.7% (68/112) in GICU group, respectively. Among 149 patients with central nervous system disease from NCU group, 90 had ischemic stroke, 28 had hemorrhagic stroke, 18 had intracranial infection, 5 had head trauma, 3 had brain tumor and 5 had other intracranial lesions (Table 1). The detail primary diagnosis for other 112 eligible patients from GICU group were also listed in Table 1. A total of 90 ischemic stroke patients suffered from SU, and their antithrombotic treatments were all suspended. Among them, 25.6% (23/90) patients restarted the antithrombotic therapy in less than a week, and there was no recurrence of SU events during hospitalization.

Table 1

Primary diagnosis of eligible patients with stress ulcer
Patients from Neurocritical Care Unit	Number (%)	Patients from General Intensive Care Unit	Number (%)
Ischemic Stroke	90(60.4)	Gastrointestinal Disease	18(16.1)
Hemorrhagic Stoke	28(18.8)	Extracranial Cardiovascular Disease	34(30.4)
Intracranial Infection	18(12.1)	Sepsis	35(31.3)
Head Trauma	5(3.4)	Extracranial Tumor	8(7.1)
Brain Tumor	3(2.0)	Other Extracranial Lesions	17(15.2)
Other Intracranial Lesions	5(3.4)

Compared with SU patients from GICU group, these SU patients from NCU group had a higher age, significantly higher prevalence of hypertension and previous stroke, but lower rates of coronary heart disease, previous peptic ulcer disease, administration of glucocorticoids or the equivalent, hepatic failure, renal failure, and coagulopathy (a platelet count ＜50000 per cubic millimeter, APTT＞2.0 times the control value or INR＞1.5). Other baseline characteristics were shown similar distributions between these two groups (Table 2). Compared with CIB patients from GICU group, the CIB patients from NCU group had a higher rate of previous stroke, but a lower rate of coronary heart disease, administration of glucocorticoids or the equivalent, renal failure, and coagulopathy (Table 3). All other baseline characteristics were similar between these two groups of CIB patients (Table 3). All together 42 patients used PPIs for SU prophylaxis, of which omeprazole, lansoprazole, pantoprazole, and rabeprazole was prescribed in 27(64.3%), 8 (19.0%), 4(9.5%) and 3(7.1%) patients, respectively.

Table 2

Characteristics of stress ulcer patients from NCU group and GICU group
Item	All patients(n = 261)	NCU group (n = 149)	GICU group (n = 112)	P Value
Age	65(53–76)	66(58–76)	61(48–77)	0.028
Female	88(33.7)	45(30.2)	43(38.4)	0.166
History
Hypertension	156(59.8)	98(65.8)	58(51.8)	0.023
Diabetes mellitus	86(33.0)	47(31.5)	39(34.8)	0.577
Hyperlipidemia	103(39.5)	60(40.3)	43(38.4)	0.759
Coronary heart disease	64(24.5)	29(19.5)	35(31.3)	0.028
Atrial fibrillation	40(15.3)	25(16.8)	15(13.4)	0.452
Previous Stroke	60(23.0)	44(29.5)	16(14.3)	0.004
Previous peptic ulcer disease	41(15.7)	16(10.7)	25(22.3)	0.011
Administration of glucocorticoids or the equivalent	67(25.7)	27(18.1)	40(35.7)	0.001
Smoker	104(39.8)	60(40.3)	44(39.3)	0.872
Heavy drinking	67(25.7)	42(28.2)	25(22.3)	0.283
length of stay	14(11–19)	14(12–17)	14(10–25)	0.650
Time interval between stress ulcer and primary diagnosis	2(1–5)	1(1–4)	2(1–6)	0.071
Coagulopathy
Platelet count ＜50000 per cubic millimeter	39(14.9)	7(4.7)	32(28.6)	＜0.001
International standardized ratio＞1.5	70(26.8)	17(11.4)	53(47.3)	＜0.001
A partial coagulation time＞2.0 times the control value	57(10.4)	12(8.1)	45(40.2)	＜
Blood glucose indicators
Fasting blood glucose(mmol/l)	6.5(5.2–9.5)	6.4(5.2–9.5)	6.5(5.3–9.6)	0.937
Glycated hemoglobin(%)	6.0(5.4-7.0)	6.0(5.4–7.4)	6.0(5.4–6.8)	0.663
Glycated albumin(%)	15.3(13.1–18.0)	15.1(13.1–19.0)	15.4(13.1–17.8)	0.232
Hepatic failure	9 (3.4)	1(0.7)	8(7.1)	0.013
Renal failure	35 (13.4)	7(4.7)	28(25.0)	＜0.001
The use of nasogastric tube	139(53.3)	78(52.3)	61(54.5)	0.735
Respiratory failure	73(28.0)	32(21.5)	41(36.6)	0.007
Pulmonary infection	123(47.1)	68(45.6)	55(49.1)	0.578
Stress ulcer prophylaxis	42(16.1)	19(12.8)	23(20.5)	0.090
Blood transfusion	59(22.6)	11(7.4)	48(42.9)	＜0.001
Underwent endoscopy	11(4.2)	2(1.3)	9(8.0)	0.008
Clinically important bleeding	136(52.1)	68(45.6)	68(60.7)	0.016
Death	57(22.0)	24(16.2)	33(29.7)	0.009
NCU; Neurocritical Care Unit, CICU; General Intensive Care Unit.

Table 3

Characteristics of CIB patients from NCU and GICU
Item	All CIB patients(n = 136)	CIB from NCU group (n = 68)	CIB from GICU group (n = 68)	P Value
Age	65(54–76)	67(59–75)	64(52–77)	0.544
Female	43(31.6)	22(32.4)	21(30.9)	0.854
History
Hypertension	84(61.8)	46(67.6)	38(55.9)	0.158
Diabetes mellitus	48(35.3)	23(33.8)	25(36.8)	0.720
Hyperlipidemia	47(34.6)	23(33.8)	24 (35.3)	0.857
Coronary heart disease	38(27.9)	13(19.1)	25(36.8)	0.022
Atrial fibrillation	25(18.4)	14(20.6)	11(16.2)	0.507
Previous Stroke	33(24.3)	24(35.3)	9(13.2)	0.003
Previous peptic ulcer disease	25(18.4)	9(13.2)	16(23.5)	0.121
Administration of glucocorticoids or the equivalent	38(27.9)	13(19.1)	25(36.8)	0.022
Smoker	59(43.4)	25(36.8)	34(50.0)	0.119
Heavy drinking	36(26.5)	17(25.0)	19(27.9)	0.697
Length of stay	14(10–25)	14(11–19)	16(10–31)	0.305
Time interval between stress ulcer and primary diagnosis	2(1–6)	2(1–5)	2(1–6)	0.556
Coagulopathy
Platelet count ＜50000 per cubic millimeter	26(19.1)	4(5.9)	22(32.4)	＜0.001
International standardized ratio＞1.5	53(39.0)	14(20.6)	39(57.4)	＜0.001
A partial coagulation time＞2.0 times the control value	43(31.6)	9(13.2)	34(50.0)	＜0.001
Blood glucose indicators
Fasting blood glucose(mmol/l)	7.4(5.5–10.4)	8.2(5.7–10.9)	7.3(5.4–9.6)	0.222
Glycated hemoglobin(%)	6.1(5.5–7.2)	6.2(5.5–7.9)	6.0(5.4–6.8)	0.243
Glycated albumin(%)	15.9(13.4–18.9)	16.4(14.0-19.6)	15.5(13.0–18.0)	0.076
Hepatic failure	7 (5.1)	1(1.5)	6(8.8)	0.052
Renal failure	27 (19.9)	4(5.9)	23(33.8)	＜0.001
The use of nasogastric tube	105(77.2)	54(79.4)	51(75.0)	0.540
Respiratory failure	63(46.3)	26(38.2)	37(54.4)	0.059
Pulmonary infection	82(60.3)	46(67.6)	36(52.9)	0.080
Stress ulcer prophylaxis	16(11.8)	6(8.8)	10(14.7)	0.287
Blood transfusion	49(36.0)	10(14.7)	39(57.4)	＜0.001
Underwent endoscopy	11(8.1)	2(2.9)	9(13.2)	0.028
Death	49(36.3)	21(30.9)	28(41.8)	0.188
CIB; Clinically important bleeding, NCU; Neurocritical Care Unit, CICU; General Intensive Care Unit.

A significantly lower mortality was observed in SU patients from NCU group than those from GICU group (16.2% versus 29.7%, P = 0.009), while there was no significant difference for death between CIB patients from NCU group and those from GICU group (30.9% versus 41.8%, P = 0.188). The risk factors for death in all eligible SU patients were shown in Table 4. Four independent risk factors, including administration of glucocorticoids or the equivalent (OR = 2.439, 95%CI, 1.131–5.259; P = 0.023), blood transfusion (OR = 3.329, 95%CI, 1.558–7.112; P = 0.002), respiratory failure (OR = 3.405, 95%CI,1.610–7.198; P = 0.001), and CIB (OR = 3.793, 95%CI, 1.529–9.414; P = 0.004) were identified in the multiple logistic regression modal (Table 4). As for the risk factors of CIB shown in the multiple logistic regression modal, SU prophylaxis served as the only protective independent factor (OR = 0.277, 95%CI, 0.100-0.768; P = 0.014), while the use of nasogastric tube (OR = 5.209, 95%CI, 2.820–9.620; P＜0.001), respiratory failure (OR = 3.672, 95%CI, 1.620–8.325; P = 0.002) and INR＞1.5 (OR = 2.119, 95CI, 1.023–4.389; P = 0.043) were associated with a greater risk of CIB (Table 5).

Table 4

Risk factors of death for all eligible stress ulcer patients
Predictors for death	Odds Ratio	95% Confidence Interval	P
Administration of glucocorticoids or the equivalent	2.439	1.131–5.259	0.023
Blood transfusion	3.329	1.558–7.112	0.002
Respiratory failure	3.405	1.610–7.198	0.001
Clinically important bleeding	3.793	1.529–9.414	0.004

Table 5

Risk factors for clinically important bleeding in stress ulcer patients
Predictors for clinically important bleeding	Odds Ratio	95% Confidence Interval	P
The use of nasogastric tube	5.209	2.820–9.620	＜0.001
Respiratory failure	3.672	1.620–8.325	0.002
Stress ulcer prophylaxis	0.277	0.100-0.768	0.014
International standardized ratio ＞1.5	2.119	1.023–4.389	0.043

Our results showed that SU patients from NCU group had a lower mortality than those from GICU group, partly because the former had a lower rate of blood transfusion and experienced less CIBs. And the mortality was similar for the CIB patients in these two groups. CIB was an independent risk factor for death in SU patients, in which SU prophylaxis could serve as a protective factor of CIB (OR = 0.277, 95%CI, 0.100-0.768; P = 0.014). In addition, the use of nasogastric tube, respiratory failure and INR＞1.5 were associated with a higher risk of CIB.

CIB increased the risk of death in SU patients perhaps through the following two mechanisms. On the one hand, CIB itself served as an acute and lethal cause that had serious adverse effect on the digestive system and circulatory system. Among them, CIB could have resulted in severe coagulation dysfunction and hemodynamic hemorrhagic shock, which directly endanger these patients' lives [2]. As showed in our study, compared with patients from NCU group, patients from GICU group were more likely to have coagulopathy, experience blood transfusion and undergo endoscopy surgery (all P < 0.05). Consistently, in a national inpatient sample from West Virginia, a significantly higher coagulopathy and mortality were also observed in CIBs from patients with ST-elevation myocardial infarction[8]. On the other hand, those SU patients with CIBs had a longer length of stay, which could have experienced more chronic complications, like severe malnutrition and pulmonary infection, leading to the deterioration of the condition and increasing the risk of long-term mortality[2]. Moreover, CIB obviously caused the dilemma of treatment for acute ischemic stroke or acute coronary syndrome, in which the sudden interruption of antithrombotic therapy could be an important risk factor for the substantial increase in these patients’ morbidity and mortality[9, 10]. Similarly, gastrointestinal bleeding was also an independent factor associated with higher risk of recurrence in ischemic stroke, in which 12.3% and 17.7% had a stroke recurrence at 3 and 12 months, respectively[11].

In keeping with results from other studies, our results suggest a protective effect of stress ulcer prophylaxis with PPIs for CIBs in both NCU group and GICU group. A 2020 systematic meta-analysis showed that acid suppressants (including PPIs and H2RBs) could significantly reduce the incidence of CIBs in adult acutely ill hospitalized patients [12]. Consistently, other studies also demonstrated the efficacy of PPIs in stress ulcer prophylaxis for CIBs [4, 13]. As for medications of stress ulcer prophylaxis in critically ill patients, the efficacy of PPIs could be much better than H2RBs[13, 14] or at least be equivalent to H2RBs[15]. That is why PPIs were already the most common acid suppressants used in the real world for SU prophylaxis and recommended in practice management guidelines[16]. However, there are still questions about stress ulcer prophylaxis with PPIs. Firstly, when to discontinue stress ulcer prophylaxis tended to vary among physicians; Secondly, concerns for adverse effects of PPIs needed to be addressed seriously. Since more than one researches have suggest that PPIs treatment was associated with an increased risk of hospital-acquired pneumonia (RR = 1.53; 95% CI, 1.04 to 2.27; P = 0.03)[17] and nosocomial Clostridium difficile infection (OR = 2.36 for PPIs; 95% CI, 1.79–3.11)[18]. Therefore, the effectiveness and safety for SU prophylaxis with acid-suppressive drug therapy (like PPIs and H2RBs) have been questioned due to the increased observance of adverse effects[6].The last but not the least, overmedication of PPIs in SU prophylaxis and irrational use of PPIs without sufficient knowledge or just unaware of any SU prophylaxis guidelines were observed frequently in clinical practice[16]. As an international survey showed that nearly one-third of intensive care units did not have a guideline for the use of SU prophylaxis[19]. Another study indicated that nearly 80% of critically ill patients have received unreasonable use of SU prophylaxis, and more than 50% of non-critically ill patients have received inappropriate use of SU prophylaxis[20]. On all accounts, the presumed risks and potentially overstated benefits of SU prophylaxis needs to be further explored.

The limitation of our study primarily resulted from the retrospective study design and small sample, and other limits faced by all non- randomized controlled trials also existed.

In short, CIB was a serious complication that increased the risk of death similarly for critically ill patients both from NCU and GICU, and SU prophylaxis with PPIs could help to decrease CIBs. The results of this study also indicated that the use of nasogastric tube, respiratory failure and INR＞1.5 were associated with a greater risk of CIBs.

Acknowledgements

None.

Authors' contributions

Huang Qiang, Sun Jin-mei, and Han Yan-fei wrote the main manuscript text. Huang Qiang and Zhang Yong-bo reviewed the manuscript.

Funding

This project was funded by Research Foundation of Beijing Friendship Hospital of Capital Medical University（No.yyqdktgl2021-10）.

Availability of data and materials

The datasets used during the current study would be available from the corresponding author upon reasonable request.

Declaration

Ethics approval and consent to participate

The study protocol and data analysis were approved by the Ethical Committee of Beijing Friendship Hospital and conform to the principles outlined in the Declaration of Helsinki. Written informed consents for the publication of these details were obtained from all patients.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Authors' information

¹ Department of Neurology, Beijing Friendship Hospital, Capital Medical University. No.95, Yongan Street, Xicheng District, Beijing, People’s Republic of China

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Factors and outcomes of stress ulcer related gastrointestinal bleeding in various intensive care units: a retrospective cohort study

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Abstract

1 Introduction

2 Methods

2.1 Explanatory and outcome variables

2.3 Statistical analysis

3 Results

4 Discussion

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