Acid suppression therapy and its association with spontaneous bacterial peritonitis incidence: A systemic review and meta‐analysis

Abstract

Aim It is well known that the use of proton pump inhibitor (PPI) is widespread in patients with liver cirrhosis. PPI counteracts H2 receptor inhibitor (H2RA) with its strong acid suppression effect. However, there is always a concern that PPI use may increase spontaneous bacteria peritonitis (SBP) development in cirrhotic patients. We aimed to investigate the association between acid suppression therapy (i.e. PPI or H2RA) and SBP through meta‐analysis. Methods We searched PubMed, Medline, Web of Science, Cochrane library, and Embase for relevant studies published up to April 2019. Pooled OR and 95% CI were calculated by a random‐effects model. Funnel plots and Egger's tests were performed for the evaluation of publication bias. Non‐parametric “trim‐and‐fill” tests were conducted for sensitivity analysis. Results A total of 20 original articles including 9566 cirrhotic patients were analyzed. The overall meta‐analysis highlighted that PPI use was associated with the risk of SBP (pooled OR 1.77, 95% CI 1.49–2.11). The conclusion was irrespective of study methods, whereas the result was inconsistent only in South America. However, the conclusion might not be stable enough and should be extrapolated with caution. Unlike PPI, we found H2RA was not associated with SBP (pooled OR 1.06, 95% CI 0.75–1.48). Conclusions In conclusion, PPI use, but not H2RA, will increase the incidence of SBP in cirrhotic patients. In addition, H2RA might be beneficial for patients who require long‐term acid suppression therapy.

Novel pathomechanism for spontaneous bacterial peritonitis: disruption of cell junctions by cellular and bacterial proteases

“…Proton pump inhibitors (PPIs) are discussed to induce dysbiosis, small intestinal bacteria overgrowth and SBP. [20][21][22][23] To exclude an influence of PPI on mucus thickness, we split our patient cohort into a PPI-untreated group and a PPI-treated group. PPI treatment had no effect on mucus thickness, neither in control nor in cirrhotic patients (figure 1B).…”

Case–control study: Proton pump inhibitor use is a major risk factor for hepatic encephalopathy after TIPS

“…Sucralfate and histamine receptor blockers have been used in cirrhotic patients for stress‐ulcer prevention, 35 and post‐band ligation prophylaxis 36,37 . Several recent multi‐center studies have shown there is no increased risk of peritonitis in patients with cirrhosis that take histamine receptor blockers 38,39 . Given the results of our analysis, we favor the discontinuation of PPIs in all patients with cirrhosis without a clear indication 34 .…”

“…36,37 Several recent multi-center studies have shown there is no increased risk of peritonitis in patients with cirrhosis that take histamine receptor blockers. 38,39 Given the results of our analysis, we favor the discontinuation of PPIs in all patients with cirrhosis without a clear indication. 34 Histamine receptor blockers and sucralfate can be considered, though there is a lack of controlled studies to support their safety.…”

Capsule endoscopy detects insufficient treatment of gastric bleeding in a dog with chronic hepatitis

“…Endoscopic haemostasis with or without therapies directed towards the host microbiota are recommended for people with GIB secondary to hepatic cirrhosis 5 6. Proton pump inhibitor therapy is generally avoided as it does not improve outcomes in humans with hepatic failure and can result in spontaneous bacterial peritonitis and increased risk for enteric infections 7. Rather, vasoactive drugs, which selectively constrict the mesenteric arterioles and reduce portal blood flow and pressure, are preferred when GIB cannot be controlled by interventional procedures alone 5.…”

“…5 6 Proton pump inhibitor therapy is generally avoided as it does not improve outcomes in humans with hepatic failure and can result in spontaneous bacterial peritonitis and increased risk for enteric infections. 7 Rather, vasoactive drugs, which selectively constrict the mesenteric arterioles and reduce portal blood flow and pressure, are preferred when GIB cannot be controlled by interventional procedures alone. 5 These interventions can help reduce patient morbidity and mortality, reduce the duration of hospitalisation and avoid the need for major surgical procedures.…”