Background/AimsAlthough proton pump inhibitors (PPIs) have been widely used for the prevention and treatment of stress gastric ulcers in hospital settings, there are concerns that PPIs increase the risk of Clostridium difficile infection (CDI). However, little is known about the risk of CDI following PPI and histamine-2 receptor antagonist (H2RA) use. We evaluated the comparative hospital-acquired CDI occurrence risk associated with the concurrent use of PPIs versus H2RAs.MethodsA systematic search of PubMed, MEDLINE/Ovid, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Google Scholar through August 19, 2016, identified 12 studies that reported the hospital-acquired CDI occurrence following H2RA and PPI use for the prevention and treatment of stress gastric ulcers. Random-effects pooled odds ratios and 95% confidence intervals were estimated. Heterogeneity was measured using I2, and a meta-regression analysis was conducted. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assess the overall quality of the evidence.ResultsA total of 74,132 patients from 12 observational studies were analyzed. Compared to H2RAs, PPIs increased the risk of CDI by 38.6% (pooled odds ratio, 1.386; 95% confidence interval, 1.152 to 1.668; p=0.001; I2=42.81%). Subgroup analyses of the purpose of study medication use, study site, and study design confirmed the consistency of a greater CDI risk with PPIs than with H2RAs. The overall quality of evidence was rated as low.ConclusionsThe use of PPIs for both the prevention and treatment of stress ulcers was associated with a 38.6% increased risk of hospital-acquired CDI occurrence compared to H2RA use.
Case Description/Methods: A 57-year-old Indian male with no past medical history presented with vague abdominal pain, pruritus, and clay colored stools. Vital signs were unremarkable and laboratory investigations revealed alkaline phosphatase 515 U/L, alanine transaminase 732 IU/L, and total bilirubin 7.6 mg/dL. The patient underwent a right upper quadrant ultrasound which showed an enlarged gallbladder and dilated common bile duct (1.9 cm) down to the level of the pancreatic head. An endoscopic ultrasound (EUS) revealed a 3.2 x 3.7 cm hypoechoic mass in the head of the pancreas obstructing the bile duct, 2 enlarged lymph nodes in the area near the bile duct, marked bile duct dilation, and an enlarged sludge-filled gallbladder. Of note, unlike most ductal tumors the pancreatic duct upstream of the mass was not dilated. Fine needle aspiration (FNA) was unsuccessful due to the obstruction by the lymph nodes. Endoscopic retrograde cholangiopancreatography (ERCP) showed stricture of bile duct consistent with a pancreatic head mass, and was stented. Abdominal and pelvic computed tomography (CT) confirmed a 3 cm pancreatic head mass. Pathology result from the attempted FNA was inconclusive. Further labs revealed normal IgG4 and CA 19-9 level of 194; indicative of possible pancreatic malignancy. The patient developed jaundice, scleral icterus and rapid weight loss. EUS with FNA with repeat biopsies revealed rare degenerated epithelial cells. The patient was treated with high dose steroids, with planned pancreaticoduodenectomy. Follow-up CT revealed resolution of the pancreatic mass and was confirmed by repeat EUS/ERCP and normal CA 19-9 level. Discussion: Although painless obstructive jaundice with a pancreatic mass is a typical presentation for a pancreatic neoplasm; it is not the only possible diagnosis. Despite biochemical and radiographic evidence suggesting a malignancy; if AIP remains in the differential, a trial of steroids may be warranted to avoid unnecessary surgical intervention and associated morbidity.
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