PPIs Should Not Be Started for Acute Gastroenteritis Without Other Indications
Proton pump inhibitors have no role in the treatment of acute gastroenteritis and should not be initiated for this indication. In fact, PPI use increases the risk of developing gastroenteritis in the first place.
Why PPIs Are Contraindicated for Acute Gastroenteritis
PPIs Increase Gastroenteritis Risk
Current PPI therapy is associated with a nearly 2-fold increased risk of bacterial gastroenteritis (adjusted OR 1.94; 95% CI 1.15-3.25), demonstrating that these medications actually predispose patients to enteric infections rather than treating them 1.
During winter viral gastroenteritis epidemics, continuous PPI use increases the risk of acute gastroenteritis by 81% (adjusted RR 1.81; 95% CI 1.72-1.90), with even higher risk in elderly patients aged 65-74 years (RR 2.19; 95% CI 1.98-2.42) 2.
The mechanism is straightforward: gastric acid serves as a critical barrier against enteric pathogens, and PPIs eliminate this protective mechanism by suppressing acid production by 37-68% over 24 hours 3.
No Therapeutic Benefit for Gastroenteritis
PPIs are indicated only for acid-related disorders including erosive esophagitis, peptic ulcer disease, GERD, Barrett's esophagus, and gastroprotection in high-risk patients on antithrombotic therapy 4.
Acute gastroenteritis—whether viral or bacterial—is not an acid-related disorder and has no pathophysiologic basis for PPI therapy 4.
Established Indications That Would Justify PPI Use
When PPIs ARE Appropriate (Even in a Patient With Gastroenteritis)
If the patient has pre-existing, documented indications for PPI therapy, these should be continued:
- History of upper GI bleeding, especially with ongoing anticoagulant or antiplatelet therapy 4
- Barrett's esophagus (PPIs reduce esophageal adenocarcinoma risk) 4
- Severe erosive esophagitis (Los Angeles Classification grade C/D) 4
- Secondary prevention of peptic ulcers in patients requiring chronic NSAID or aspirin therapy 4
- High bleeding risk on antithrombotic therapy: history of upper GI bleeding, multiple antithrombotics, or aspirin/NSAIDs with additional risk factors 3, 5
Special Consideration: Stress Ulcer Prophylaxis
The only scenario where PPIs might be considered in acute illness is stress ulcer prophylaxis in ICU patients with risk factors (mechanical ventilation >48 hours, coagulopathy, high-dose corticosteroids, severe burns, traumatic brain injury) 4.
However, acute gastroenteritis alone—even if requiring hospitalization—does not constitute an indication for stress ulcer prophylaxis unless the patient meets ICU-level criteria 4.
PPIs for stress ulcer prophylaxis should be discontinued immediately upon ICU discharge unless another definitive indication exists 6.
Critical Clinical Pitfalls to Avoid
Common Prescribing Errors
Do not prescribe PPIs empirically for nausea, vomiting, or abdominal discomfort associated with gastroenteritis—these symptoms do not respond to acid suppression 4.
Do not confuse gastroenteritis with gastritis or peptic disease—gastroenteritis is an infectious/inflammatory process of the intestinal tract, not an acid-mediated upper GI disorder 4.
Up to 70% of PPI prescriptions may be inappropriate, and gastroenteritis represents a classic example of inappropriate indication 7.
Risk of Inappropriate Continuation
Once started, PPIs are frequently continued indefinitely without reassessment—a single inappropriate prescription for gastroenteritis may lead to years of unnecessary therapy 4.
Rebound acid hypersecretion occurs after PPI discontinuation, lasting 2-6 months, which can perpetuate inappropriate use if patients interpret withdrawal symptoms as need for continued therapy 4, 7.
Evidence-Based Management Approach
For Patients Presenting With Acute Gastroenteritis
Assess for pre-existing PPI indications by reviewing medication history and past medical history 4
If no documented indication exists, do not initiate PPI therapy 4
If patient is already on a PPI for a valid indication, continue it—do not discontinue during acute illness if the underlying indication persists 4
Provide supportive care (hydration, antiemetics if needed, dietary modification) without acid suppression 4
Documentation Requirements
All PPI prescriptions should have clearly documented indications in the medical record, with regular review by the primary care provider 4.
The absence of an appropriate ongoing indication means the medication can only incur harm—including pill burden, cost, and potential adverse effects 4.
The Bottom Line
Acute gastroenteritis is not an indication for PPI therapy under any circumstances. PPIs increase susceptibility to enteric infections and provide no therapeutic benefit for gastroenteritis. Only continue PPIs in patients with pre-existing, documented acid-related indications. The widespread inappropriate use of PPIs—with up to 70% lacking valid indications—represents a significant quality-of-care issue that gastroenterologists and primary care providers must actively address 4, 7.