Proton pump inhibitors increase the severity of hepatic encephalopathy in cirrhotic patients

Matthew Fasullo, Prashanth Rau, Dong Qi Liu, Erik Holzwanger, Jomol P. Mathew, Yurima Guilarte-Walker, G. Szabó

Research output: Contribution to journalArticle

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Abstract

BACKGROUND Liver cirrhosis is the late stage of hepatic fibrosis and is characterized by portal hypertension that can clinically lead to decompensation in the form of ascites, esophageal/gastric varices or encephalopathy. The most common sequelae associated with liver cirrhosis are neurologic and neuropsychiatric impairments labeled as hepatic encephalopathy (HE). Well established triggers for HE include infection, gastrointestinal bleeding, constipation, and medications. Alterations to the gut microbiome is one of the leading ammonia producers in the body, and therefore may make patients more susceptible to HE. AIM To investigate the relationship between the use of proton pump inhibitors (PPIs) and HE in patients with cirrhosis. METHODS This is a single center, retrospective analysis. Patients were included in the study with an admitting diagnosis of HE. The degree of HE was determined from subjective and objective portions of hospital admission notes using the West Haven Criteria. The primary outcome of the study was to evaluate the grade of HE in PPI users versus non-users at admission to the hospital and throughout their hospital course. Secondary outcomes included rate of infection, gastrointestinal bleeding within the last 12 mo, mean ammonia level, and model for end-stage liver disease scores at admission.RESULTS The HE grade at admission using the West Haven Criteria was 2.3 in the PPI group compared to 1.7 in the PPI nonuser group (P = 0.001). The average length of hospital stay in PPI group was 8.3 d compared to 6.5 d in PPI nonusers (P = 0.046). Twenty-seven (31.8%) patients in the PPI user group required an Intensive Care Unit admission during their hospital course compared to 6 in the PPI nonuser group (16.7%) (P = 0.138). Finally, 10 (11.8%) patients in the PPI group expired during their hospital stay compared to 1 in the PPI nonuser group (2.8%) (P = 0.220). CONCLUSION Chronic PPI use in cirrhotic patients is associated with significantly higher average West Haven Criteria for HE compared to patients that do not use PPIs.

Original languageEnglish
Pages (from-to)522-530
Number of pages9
JournalWorld Journal of Hepatology
Volume11
Issue number6
DOIs
Publication statusPublished - Jan 1 2019

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Hepatic Encephalopathy
Proton Pump Inhibitors
Length of Stay
Ammonia
Liver Cirrhosis
Fibrosis
Hemorrhage
End Stage Liver Disease
Esophageal and Gastric Varices
Brain Diseases
Portal Hypertension
Constipation
Infection
Ascites
Nervous System
Intensive Care Units
Outcome Assessment (Health Care)

Keywords

  • Cirrhosis
  • Hepatic encephalopathy
  • Hepatology
  • Proton pump inhibitor
  • Proton pump inhibitors

ASJC Scopus subject areas

  • Hepatology

Cite this

Proton pump inhibitors increase the severity of hepatic encephalopathy in cirrhotic patients. / Fasullo, Matthew; Rau, Prashanth; Liu, Dong Qi; Holzwanger, Erik; Mathew, Jomol P.; Guilarte-Walker, Yurima; Szabó, G.

In: World Journal of Hepatology, Vol. 11, No. 6, 01.01.2019, p. 522-530.

Research output: Contribution to journalArticle

Fasullo, M, Rau, P, Liu, DQ, Holzwanger, E, Mathew, JP, Guilarte-Walker, Y & Szabó, G 2019, 'Proton pump inhibitors increase the severity of hepatic encephalopathy in cirrhotic patients', World Journal of Hepatology, vol. 11, no. 6, pp. 522-530. https://doi.org/10.4254/wjh.v11.i6.522
Fasullo M, Rau P, Liu DQ, Holzwanger E, Mathew JP, Guilarte-Walker Y et al. Proton pump inhibitors increase the severity of hepatic encephalopathy in cirrhotic patients. World Journal of Hepatology. 2019 Jan 1;11(6):522-530. https://doi.org/10.4254/wjh.v11.i6.522
Fasullo, Matthew ; Rau, Prashanth ; Liu, Dong Qi ; Holzwanger, Erik ; Mathew, Jomol P. ; Guilarte-Walker, Yurima ; Szabó, G. / Proton pump inhibitors increase the severity of hepatic encephalopathy in cirrhotic patients. In: World Journal of Hepatology. 2019 ; Vol. 11, No. 6. pp. 522-530.
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abstract = "BACKGROUND Liver cirrhosis is the late stage of hepatic fibrosis and is characterized by portal hypertension that can clinically lead to decompensation in the form of ascites, esophageal/gastric varices or encephalopathy. The most common sequelae associated with liver cirrhosis are neurologic and neuropsychiatric impairments labeled as hepatic encephalopathy (HE). Well established triggers for HE include infection, gastrointestinal bleeding, constipation, and medications. Alterations to the gut microbiome is one of the leading ammonia producers in the body, and therefore may make patients more susceptible to HE. AIM To investigate the relationship between the use of proton pump inhibitors (PPIs) and HE in patients with cirrhosis. METHODS This is a single center, retrospective analysis. Patients were included in the study with an admitting diagnosis of HE. The degree of HE was determined from subjective and objective portions of hospital admission notes using the West Haven Criteria. The primary outcome of the study was to evaluate the grade of HE in PPI users versus non-users at admission to the hospital and throughout their hospital course. Secondary outcomes included rate of infection, gastrointestinal bleeding within the last 12 mo, mean ammonia level, and model for end-stage liver disease scores at admission.RESULTS The HE grade at admission using the West Haven Criteria was 2.3 in the PPI group compared to 1.7 in the PPI nonuser group (P = 0.001). The average length of hospital stay in PPI group was 8.3 d compared to 6.5 d in PPI nonusers (P = 0.046). Twenty-seven (31.8{\%}) patients in the PPI user group required an Intensive Care Unit admission during their hospital course compared to 6 in the PPI nonuser group (16.7{\%}) (P = 0.138). Finally, 10 (11.8{\%}) patients in the PPI group expired during their hospital stay compared to 1 in the PPI nonuser group (2.8{\%}) (P = 0.220). CONCLUSION Chronic PPI use in cirrhotic patients is associated with significantly higher average West Haven Criteria for HE compared to patients that do not use PPIs.",
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AU - Rau, Prashanth

AU - Liu, Dong Qi

AU - Holzwanger, Erik

AU - Mathew, Jomol P.

AU - Guilarte-Walker, Yurima

AU - Szabó, G.

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N2 - BACKGROUND Liver cirrhosis is the late stage of hepatic fibrosis and is characterized by portal hypertension that can clinically lead to decompensation in the form of ascites, esophageal/gastric varices or encephalopathy. The most common sequelae associated with liver cirrhosis are neurologic and neuropsychiatric impairments labeled as hepatic encephalopathy (HE). Well established triggers for HE include infection, gastrointestinal bleeding, constipation, and medications. Alterations to the gut microbiome is one of the leading ammonia producers in the body, and therefore may make patients more susceptible to HE. AIM To investigate the relationship between the use of proton pump inhibitors (PPIs) and HE in patients with cirrhosis. METHODS This is a single center, retrospective analysis. Patients were included in the study with an admitting diagnosis of HE. The degree of HE was determined from subjective and objective portions of hospital admission notes using the West Haven Criteria. The primary outcome of the study was to evaluate the grade of HE in PPI users versus non-users at admission to the hospital and throughout their hospital course. Secondary outcomes included rate of infection, gastrointestinal bleeding within the last 12 mo, mean ammonia level, and model for end-stage liver disease scores at admission.RESULTS The HE grade at admission using the West Haven Criteria was 2.3 in the PPI group compared to 1.7 in the PPI nonuser group (P = 0.001). The average length of hospital stay in PPI group was 8.3 d compared to 6.5 d in PPI nonusers (P = 0.046). Twenty-seven (31.8%) patients in the PPI user group required an Intensive Care Unit admission during their hospital course compared to 6 in the PPI nonuser group (16.7%) (P = 0.138). Finally, 10 (11.8%) patients in the PPI group expired during their hospital stay compared to 1 in the PPI nonuser group (2.8%) (P = 0.220). CONCLUSION Chronic PPI use in cirrhotic patients is associated with significantly higher average West Haven Criteria for HE compared to patients that do not use PPIs.

AB - BACKGROUND Liver cirrhosis is the late stage of hepatic fibrosis and is characterized by portal hypertension that can clinically lead to decompensation in the form of ascites, esophageal/gastric varices or encephalopathy. The most common sequelae associated with liver cirrhosis are neurologic and neuropsychiatric impairments labeled as hepatic encephalopathy (HE). Well established triggers for HE include infection, gastrointestinal bleeding, constipation, and medications. Alterations to the gut microbiome is one of the leading ammonia producers in the body, and therefore may make patients more susceptible to HE. AIM To investigate the relationship between the use of proton pump inhibitors (PPIs) and HE in patients with cirrhosis. METHODS This is a single center, retrospective analysis. Patients were included in the study with an admitting diagnosis of HE. The degree of HE was determined from subjective and objective portions of hospital admission notes using the West Haven Criteria. The primary outcome of the study was to evaluate the grade of HE in PPI users versus non-users at admission to the hospital and throughout their hospital course. Secondary outcomes included rate of infection, gastrointestinal bleeding within the last 12 mo, mean ammonia level, and model for end-stage liver disease scores at admission.RESULTS The HE grade at admission using the West Haven Criteria was 2.3 in the PPI group compared to 1.7 in the PPI nonuser group (P = 0.001). The average length of hospital stay in PPI group was 8.3 d compared to 6.5 d in PPI nonusers (P = 0.046). Twenty-seven (31.8%) patients in the PPI user group required an Intensive Care Unit admission during their hospital course compared to 6 in the PPI nonuser group (16.7%) (P = 0.138). Finally, 10 (11.8%) patients in the PPI group expired during their hospital stay compared to 1 in the PPI nonuser group (2.8%) (P = 0.220). CONCLUSION Chronic PPI use in cirrhotic patients is associated with significantly higher average West Haven Criteria for HE compared to patients that do not use PPIs.

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