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ANN SAUDI MED 2016 NOVEMBER-DECEMBER WWW.ANNSAUDIMED.NET 434 Gastrointestinal bleeding is a major source of morbidity and is associated with a high mortality in patients who are critically ill and managed in the intensive care setting.1 Fortunately, the incidence of clinically significant gastrointestinal bleeding is much lower than initially anticipated. Nonetheless, an incidence of 1% is worth preventing. The underlying cause of gastrointestinal bleeding in the intensive care unit (ICU) is attributed to stress related mucosal disease (SRMD). Interventions that can decrease the incidence include enteral nutrition and, currently the source of controversy, acid suppressive therapy. Stress ulcer bleeding prophylaxis has become the standard of care in ICUs despite the uncertainty in the timing of initiation,2 the most efficacious agent to be used, and lack of any proven effect on mortality.1,3 The use of these acid suppressive therapies is associated with some concerns like the potential association with nosocomial infections mainly ventilatorassociated pneumonia, as well as Clostridium difficile infection, further adding to the general uncertainty about the cost-effectiveness of stress ulcer bleeding prophylaxis. Also, the target population that should receive prophylaxis has evolved from those that require prolonged ventilation, burns and head trauma to those with acute kidney injury, coagulopathy (platelet count <50 000/mL3, international normalized ratio >1.5, or partial-thromboplastin time more than two times the control value), and acute hepatic injury as well as those with chronic liver disease.1 Furthermore, the most cost-effective strategy for the prevention of gastrointestinal bleeding is controversial given the quality and size of these studies as well as the discrepancy in the variables included in calculating estimates.1 Intensive care unit stress ulcer prophylaxis: is it still needed?