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Goals and Background: Stress ulcer prophylaxis has been shown to lower gastrointestinal bleeding (GIB) rates. Various agents have been studied, and the optimal strategy continues to be contested. This study evaluates the efficacy between proton pump inhibitors (PPIs) and histamine-2-receptor antagonists. Small sample sizes and methodology flaws limited prior studies.Study: A systematic search of MEDLINE, EMBASE, CENTRAL, Web of Science, and ClinicalTrials.gov for randomized controlled trials reporting the use of PPI and histamine-2-receptor antagonist reporting rates of GIB and standardized intensive care outcomes. Risk ratios (RR) and standardized mean difference (SMD) with 95% confidence intervals (CIs). A trial sequential analysis was performed to guard against errors.Results: A total of 14 randomized controlled trials of 28,526 patients with a mean age of 57.83 ± 17.35 years and 30.82% females. In our pooled analysis, PPI outperformed its comparator (RR: 0.68; 95% CI: 0.57-0.82) in clinically significant GIB. PPI re-demonstrated significant reduction in overt GIB (RR: 0.61; 95% CI: 0.39-0.97). No differences between groups was noted toward all-cause mortality (RR: 1.05; 95% CI: 1.00-1.10) or incidence of pneumonia (RR: 1.11; 95% CI: 0.82-1.51). Duration of stay (SMD: 0.07; 95% CI: −0.04-0.17) and ventilator days (SMD: 0.01; 95% CI: −0.01-0.04) were indifferent between the groups.Conclusions: Among critically ill patients, PPI was associated with reduced clinically significant or overt GIB. No differences in pneumonia were seen with the use of either agent. Trial sequential analysis for clinically significant GIB ruled out the risk for false-positive results, and thereby it is unlikely that future trials will affect our conclusions.

Background and study aims Endoscopic methods of delivering uninterrupted feeding to the jejunum include direct percutaneous endoscopic jejunostomy (DPEJ) or PEG with jejunal extension (PEG-J), validated from small individual studies. We aim to perform a meta-analysis to assess their effectiveness and safety in a variety of clinical scenarios. Methods Major databases were searched until June 2021. Efficacy outcomes included technical and clinical success, while safety outcomes included adverse events (AEs) and malfunction rates. We assessed heterogeneity using I2 and classic fail-safe to assess bias. Results 29 studies included 1874 patients (983 males and 809 females); mean age of 60 ± 19 years. Pooled technical and clinical success rates with DPEJ were 86.6 % (CI, 82.1–90.1, I2 73.1) and 96.9 % (CI, 95.0–98.0, I2 12.7). The pooled incidence of malfunction, major and minor AEs with DPEJ were 11 %, 5 %, and 15 %. Pooled technical and clinical success for PEG-J were 94.4 % (CI, 85.5–97.9, I2 33) and 98.7 % (CI, 95.5–99.6, I2  < 0.001). The pooled incidence of malfunction, major and minor AEs with DPEJ were 24 %, 1 %, and 25 %. Device-assisted DPEJ performed better in altered gastrointestinal anatomy. First and second attempts were 87.6 % and 90.2 %. Conclusions DPEJ and PEG-J are safe and effective procedures placed with high fidelity with comparable outcomes. DPEJ was associated with fewer tube malfunction and failure rates; however, it is technically more complex and not standardized, while PEG-J had higher placement rates. The use of balloon enteroscopy was found to enhance DPEJ performance.