Cirrhosis of the liver and acid blockers (PPIs) – a bad combination?


There is more and more evidence that patients who have cirrhosis who also take acid blockers known as proton pump inhibitors (PPIs, such as omeprazole and others) are at increased the risk of getting serious complications. These are spontaneous bacterial peritonitis, and hepatic encephalopathy. Experts recommend limiting the use of PPIs in patients with cirrhosis to those who really need them, and then only at the lowest effective dose and shortest duration needed.Authority: Li, D. K. and Chung, R. T. (2017), Use of proton pump inhibitors in chronic liver diseases. Clinical Liver Disease, 10: 148–151. doi: 10.1002/cld.678


What is hepatic encephalopathy?

Cirrhosis of the liver is advanced scarring of the liver and as the scarring worsens, serious complications may arise such as bleeding from esophageal varices, spontaneous bacterial peritonitis, and hepatic encephalopathy. Hepatic encephalopathy is a condition that leads to confusion, slows down thinking, and may affect the sleep pattern, body movements and mood. There are many factors that can make hepatic encephalopathy worse and medications are available for treatment. However, it is best to avoid triggers of hepatic encephalopathy, and the newest trigger seems to be proton pump inhibitors.

What is spontaneous bacterial peritonitis?

As cirrhosis advances and the scarring of the liver increases, the blood from the intestines arriving via the portal vein has a hard time going through the liver to return to the heart. One or two things can occur alone or in combination: 1) The blood is looking to bypass the liver, veins in the esophagus can enlarge (and may rupture causing bleeding). 2) The scarred liver starts to leak watery fluid contained in the blood into the abdominal cavity, this is called ascites.

A scarred liver forces fluid from the blood into the abdominal cavity. This fluid is called ascites. Ascites can get infected and lead to peritonitis.

Ascites is a special fluid because it contains all the nutrition bacteria need to grow but few of the immune defenses that the blood contains. This fluid can easily (spontaneously) get infected by stray bacteria that may be circulated in the blood stream. These bacteria would be killed soon in the blood but once they get into the ascites, they are safe to multiply and may cause a dangerous, potentially life-threatening condition, peritonitis. Peritonitis is inflammation of the lining of the abdominal cavity, unfortunately, in patients with cirrhosis it causes few symptoms, but may be deadly. It seems that proton pump inhibitors can increase the risk of spontaneous bacterial peritonitis (SBP).

How many patients with cirrhosis are on proton-pump inhibitors?

It turns out that, depending on study, between 37 % and 86 % of patients with cirrhosis take PPIs. Concerning is that between 34 % to 74 % of those taking them had no good reason for continuing them. However, it is also worth noting that short term use of PPIs is a good practice after variceal band ligation.

If you currently take PPIs and have cirrhosis, talk to your doctor about it or make an appointment with Dr. Klaus Gottlieb, a gastroenterologist with a special interest in liver disease, in San Luis Obispo, CA, or Templeton, CA.

For more scientific background:
Li, D. K. and Chung, R. T. (2017), Use of proton pump inhibitors in chronic liver diseases. Clinical Liver Disease, 10: 148–151. doi: 10.1002/cld.678






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