title: Proton pump inhibitor use and association with spontaneous bacterial peritonitis in patients with cirrhosis and ascites.
abstract: OBJECTIVE
  To evaluate the literature regarding the efficacy and safety of proton pump inhibitors (PPIs) when they are used in patients with cirrhosis and ascites.
  
  
  METHODS
  A literature search was conducted using MEDLINE (1966-May 2012) and Web of Science (1990-May 2012) with the terms proton pump inhibitor, antisecretory therapy, cirrhosis, ascites, spontaneous bacterial peritonitis, and Clostridium difficile. The search was restricted to articles published in English on the use of PPIs in humans. Reference citations from identified published articles were reviewed for relevant information.
  
  
  METHODS
  All articles in English identified from the data sources were evaluated for inclusion. One case series, 8 retrospective case-control trials, and 1 meta-analysis were identified.
  
  
  RESULTS
  Cirrhosis may cause complications such as portal hypertension, esophageal varices, and ascites. Patients may be prescribed PPIs without clear indications or because of their propensity to develop upper gastrointestinal symptoms and bleeding. However, gastric acidity is a major nonspecific defense mechanism and there is insufficient evidence on the need for chronic acid suppression in patients with cirrhosis. It is postulated that the portal hypertensive environment in cirrhosis and the acid suppression from PPIs can increase the risk of spontaneous bacterial peritonitis and C. difficile infection in patients with cirrhosis with ascites. Several retrospective studies and 1 meta-analysis have confirmed this association.
  
  
  CONCLUSIONS
  Patients with cirrhosis and ascites should be monitored carefully while on PPIs for a possible increased risk of infection from spontaneous bacterial peritonitis and C. difficile. Prospective randomized trials are needed to confirm this association. Clinicians should be aware of this lesser known adverse effect of PPIs.
authors.affiliation: Vancouver Primary Care, Portland Veterans Affairs Medical Center, WA, USA. jolene.siple@va.gov
authors.forename: Jolene F
authors.initials: JF
authors.lastname: Siple
authors.forename: Jessica M
authors.initials: JM
authors.lastname: Morey
authors.forename: Tracy E
authors.initials: TE
authors.lastname: Gutman
authors.forename: Kathy L
authors.initials: KL
authors.lastname: Weinberg
authors.forename: Peggie D
authors.initials: PD
authors.lastname: Collins
mesh_terms: D001201:Ascites / Q000188:drug therapy; D001424:Bacterial Infections / Q000150:complications*; D005355:Fibrosis / Q000150:complications* / Q000188:drug therapy; D006801:Humans; D010538:Peritonitis / Q000150:complications*; D054328:Proton Pump Inhibitors / Q000627:therapeutic use*
chemical_list: D054328:Proton Pump Inhibitors