From the Research
The recommended prophylaxis for gastric ulcers in patients with spontaneous bacterial peritonitis (SBP) is a proton pump inhibitor (PPI) such as omeprazole 20-40 mg daily or pantoprazole 40 mg daily, despite concerns about potential increased risk of SBP with PPI use, as the most recent and highest quality evidence suggests that PPI therapy does not increase the incidence of SBP in cirrhotic patients with ascites 1.
Key Considerations
- Patients with SBP often have advanced liver disease and are at increased risk for stress-related mucosal damage and bleeding.
- PPIs work by reducing gastric acid production, which helps protect the gastric mucosa from damage.
- Histamine-2 receptor antagonists (H2RAs) like ranitidine 150 mg twice daily can be used as an alternative if PPIs are contraindicated, though they are generally less effective.
- It's essential to reassess the need for continued acid suppression therapy upon hospital discharge to avoid potential complications of long-term PPI use, including increased risk of recurrent SBP, Clostridium difficile infection, and pneumonia.
Additional Therapy
- In patients with varices or a history of variceal bleeding, non-selective beta-blockers may be used concurrently as they reduce portal pressure and decrease bleeding risk.
- The use of PPIs should be carefully evaluated, and their benefits should be weighed against potential risks, as some studies have suggested an association between PPI therapy and SBP in cirrhotic patients with ascites 2.
Evidence Summary
- A prospective study published in 2015 found no significant difference in the rate of PPI consumption between infected and non-infected patients, or between SBP patients and patients with ascites without SBP 1.
- Another study published in 2009 suggested an association between PPI use and SBP in cirrhotic patients with ascites, but this finding has been disputed by more recent evidence 2.
- The most recent and highest quality evidence should be prioritized when making clinical decisions, and in this case, it suggests that PPI therapy does not increase the incidence of SBP in cirrhotic patients with ascites 1.