2025 Southeastern Residency Conference

Title: Proton Pump Inhibitor Use in Patients with Cirrhosis and its Association with Spontaneous Bacterial Peritonitis
 
​​​​Authors: Morgan Thomas, Cameron Lanier, Kelly Covert 
 
Objective: To determine the incidence of first episode of spontaneous bacterial peritonitis in patients with cirrhosis who are on proton pump inhibitor therapy. 
 
Self-Assessment Question: True or False. The American Association for the Study of Liver Disease recommends avoiding proton pump inhibitors (PPIs) in cirrhotic patients admitted with acute on chronic liver failure unless there is a clear indication.

Background: Liver cirrhosis is a significant source of mortality and morbidity in the United States. Advanced liver dysfunction in cirrhosis causes an alteration of the immune system and promotes bacterial translocation which increases patients’ susceptibility to infection such as spontaneous bacterial peritonitis (SBP). Risk factors for SBP include upper gastrointestinal bleeds, previous SBP episodes, low ascitic protein, and elevated MELD scores. In addition to these proven risk factors, it is hypothesized that proton pump inhibitors (PPIs) may contribute to SBP. The goal of this study is to evaluate the impact of PPIs on SBP development in patients with cirrhosis. Additionally, this study will evaluate the appropriateness of PPI medication choice, dose, duration of therapy, and documented indication for PPI therapy.
 
Methods: Eligible patients were those >18 years old with diagnosis of cirrhosis (by ICD-10 codes) admitted to a Ballad Health Facility for SBP rule out between the dates of June 1, 2022 - June 31, 2024. Patients were excluded if they were pregnant, incarcerated, or had a recent (within 2 weeks of hospitalization) or current upper gastrointestinal or variceal bleed. The primary objective of this study is to determine the incidence of first episode of spontaneous bacterial peritonitis in patients with cirrhosis who are on proton pump inhibitor therapy. Secondary outcomes included the documented indications for PPI therapy, the rate of PPI therapy usage prior to admission, in-hospital mortality rate, and the incidence of new or worsening ascites, esophageal varices, and hepatorenal syndrome.
 
Results: Eighty-one patients were included in this IRB-approved study, with 42 receiving PPI therapy prior to admission and 39 who were not. The incidence of SBP was 33.3% among patients receiving home PPI therapy, compared to 20.5% in those not on PPI therapy (χ² = 0.249, p = 0.618). Across the entire cohort, 99% experienced new or worsening ascites, 42% developed new or worsening hepatic encephalopathy, 11% had newly identified esophageal varices, and 21% developed new hepatorenal syndrome. Documentation of the clinical indication for PPI therapy was infrequent. The median hospital length of stay was 6 days (IQR 3–11). Additionally, 29.6% of patients required ICU admission, 9.9% died during hospitalization, and 4.9% underwent hemodialysis.
 
Conclusion: This retrospective chart review found no statistically significant increase in the incidence of SBP among cirrhotic patients receiving PPI therapy. Key limitations of the study include its retrospective design, limited information on the duration of PPI use prior to admission, and a relatively small sample size. Larger, prospective studies are warranted to more accurately assess the potential role of PPI therapy in the pathogenesis of SBP in patients with decompensated cirrhosis.