Is the Use of Proton Pump Inhibitors a Predisposing Factor for Pyogenic Liver Abscesses?

Abstract

Background: Proton pump inhibitors (PPIs) increase gastric pH by reducing acid production. The resulting alkaline milieu in the stomach increases the risk of bacterial translocation. This study aimed to investigate if there is a correlation between PPI use and developing pyogenic liver abscesses. Methods:In this retrospective case-control analysis, we studied adult patients diagnosed with cryptogenic liver abscess at Northwell hospitals between 2015 and 2019. Adult patients with the diagnosis of liver abscess were included. We excluded patients with history of liver abscess prior to admission, biliary disease, hepatobiliary malignancy, or intra-abdominal infections. A group of randomly selected patients without liver abscess from the same hospitals' database were enrolled as the control group. A multivariate logistic regression analysis was performed to adjust for potential confounding factors. Results:We identified 277 patients diagnosed with first episode of pyogenic liver abscess. Cases were compared to 554 controls. Klebsiella pneumonia was the most common pathogen. PPI use was associated with an increased risk of developing a first episode of pyogenic liver abscess in univariate (odds ratio (OR): 2.36, 95% confidence interval (CI): 1.70 -3.27), and multivariate analysis (adjusted OR: 2.27, 95% CI: 1.55 -3.32). Conclusion:This study is the first US population-based analysis to demonstrate that PPI use is associated with increased risk of developing pyogenic liver abscesses. Further prospective studies are needed to shed more light on this association and better evaluate the impact of dose and duration of PPI exposure.

A case of pheochromocytoma associated with liver abscess and intestinal pseudo-obstruction

“…We suspected that prolonged intestinal pseudo-obstruction led to bacterial growth in the intestinal tract and caused bacterial seeding into the enterohepatic circulation via the portal venous system, eventually resulting in a liver abscess. In addition, Elfiky et al 14 recently reported that patients using PPIs are associated with 2.36 times increased risk of developing liver abscess because PPIs elevate the gastric pH, thus increasing the risk of bacterial translocation. Our patient had been prescribed a PPI, namely, lansoprazole, for more than a year.…”

The impact of proton pump inhibitors in liver diseases and the effects on the liver

“…143 In a recent case-control study, PPI use similarly increased the risk of septic liver abscess (aOR 2.27, 95% CI 1.55-3.32). 141 PPIs also appeared to lead to a worse prognosis for liver abscess. 16 PPIs were associated with increased index mortality in individuals with liver abscess, and after adjusted for confounding factors, PPIs remained an independent predictor (adjusted OR 2.56, 95% CI 1.01-6.46).…”

“…Another study not only found that PPIs were responsible for an increased risk of liver abscess, but also revealed that there was a dose–response relationship, as PPIs accumulated within 90 days of PPI initiation 143 . In a recent case–control study, PPI use similarly increased the risk of septic liver abscess (aOR 2.27, 95% CI 1.55–3.32) 141 . PPIs also appeared to lead to a worse prognosis for liver abscess 16 .…”

“…PPIs have been shown to increase colonization of Klebsiella pneumoniae , the most common causative organism of liver abscess, in the gut due to altered composition of the gut microflora and promoted translocation of gut bacteria (Figure 1). 141 Current PPI users (less than 30 days prior to admission due to liver abscess) significantly increased the incidence of liver abscesses in a population‐based case–control study compared to nonusers (adjusted OR 7.59, 95% CI 5.05–11.4) 142 . Another study not only found that PPIs were responsible for an increased risk of liver abscess, but also revealed that there was a dose–response relationship, as PPIs accumulated within 90 days of PPI initiation 143 .…”