Stopping Proton Pump Inhibitors Research Articles

Hypoxia-inducible factor-1α mediates reflux-induced epithelial-mesenchymal plasticity in Barrett’s oesophagus patients

IntroductionEpithelial-mesenchymal plasticity (EMP), the process through which epithelial cells acquire mesenchymal features, is needed for wound repair but also might contribute to cancer initiation. Earlier, in vitro studies showed that...

Trends of Proton Pump Inhibitor Uses among Pharmaceutical Promotional Workers

Background: Proton pump inhibitors (PPIs) are one of the most frequently used drugs in the world for the management of gastric- acid related diseases. The aim of this study was to assess the trend of PPIs uses among the pharmaceutical promotional workers in Bangladesh. Methods: A questionnaire-based survey was conducted on pharmaceutical promotional workers from different regions in Bangladesh. The study data were collected which includes demographics, PPIs uses in terms of duration, dose, generics, symptoms for which they took PPIs and effects of PPIs on symptoms. Drugs or diseases that influenced the intake of PPIs were also recorded. Results: Among six hundred surveys issued for the study, 581 valid questionnaires were returned. Among the respondents 520 individuals (89.5%) were male and 61 individuals (10.5%) were female. Common indications for taking PPIs were abdominal discomfort (51.5%), vomiting (34.1%) and abdominal pain (24.6%). Two hundred seventy (48.56%) respondents had satisfactory relief of symptoms, 125 (22.48%) had symptoms reappeared after stopping PPIs and 77 (13.85%) had complete cure of symptoms. Most of the participants (42.60%) were on PPIs therapy for up to one year. Most of the participants (64.49%) took PPI once daily. Most of the participants (60.75%) started PPI by themselves. Esomeprazole (40.1%) and rabeprazole (30.1%) were the most frequently used PPIs. Conclusion: PPI is found to be a frequently used medication among pharmaceutical promotional workers. Further well-designed study with adequate work up may be designed to see misuse and overuse of PPI among workers of pharmaceutical sector as well as general population. Sir Salimullah Med Coll J 2023; 31: 41-46

Randomised clinical trial: the use of alginates during preinvestigation proton pump inhibitor wash-out and their impact on compliance and symptom burden

Background/aimsInvestigation of gastro-oesophageal reflux disease is usually performed off proton pump inhibitors (PPIs). This can exacerbate symptoms, potentially impacting investigation accuracy if patients circumvent the preinvestigation instructions. There are no...

Assessment of Esophageal Motility Disorders in Patients With Refractory Gastroesophageal Reflux Disease

There is insufficient data about esophageal body dysmotility in patients with refractory gastroesophageal reflux disease (RGERD) and inadequate response to proton pump inhibitors (PPIs) treatment. This study aimed to assess esophageal motility disorder and reflux parameters among these patients by high-resolution manometry (HRM) and intraluminal impedance and pH (MII‐pH) monitoring after stopping PPI therapy. A retrospective study was conducted among 100 RGERD patients admitted to Taleghani Hospital (Tehran, Iran) for one year. More than half of them were males (55%). Their mean age was 47.10±6.92, and 50% of patients had ineffective esophageal motility (IEM). Middle, distal, and proximal esophageal pressure (MEP, DEP, and PEP), lower esophageal sphincter (LES) basal pressure (LESP), integrated relaxation pressure (IRP), distal contractile integral (DCI), large breaks, upper esophageal sphincter basal pressure (UESP), and LES length (LESL) in IEM patients were significantly lower than the patients with normal esophageal motility (P<0.001). Furthermore, there were more patients in the IEM group with long-term and abnormal weakly acid reflux compared with the non-IEM group (P<0.05). It seems that the evaluation of reflux parameters and esophageal motility could lead to additional insights into the pathophysiological mechanisms of RGERD. Nevertheless, further studies are suggested to evaluate the effects of esophageal motility disorders among RGERD patients.

Understanding the Patient PPI Journey: Results of a Survey on PPI Treatment Initiation and Patient Experience.

Introduction:Proton pump inhibitors (PPIs) used in the management of gastro-esophageal reflux disease (GORD) are among the most frequently prescribed classes of drug worldwide. Currently, however, physicians are prescribing PPIs for extended periods, often without an indication, which is not in line with current guidance and therefore preventing appropriate reflux management. Inappropriate or excessive PPI prescribing is becoming increasingly visible, yet there is currently little research available on the impact such current practice has on the patient experience. This study aims to understand patient attitudes toward their PPI treatment and the impact current PPI prescribing patterns have on the patient experience.Methods:An online survey of current and previous users of PPI for GORD was conducted in the UK and Germany. Topics covered included prior steps taken before first consultation with a physician, initial recommendations, PPI treatment initiation and duration, use of PPI, management of reflux whilst taking a PPI, stopping PPI treatment, and patient attitudes.Results:Among 566 patient participants (UK, n = 372; Germany, n = 194) 69% to 79% reported being prescribed medication at their first visit to a physician, of which 61% to 68% were prescribed a PPI either alone or combined with another treatment. 41% to 48% of patients answered “don’t know” when asked how long they expected to continue taking their PPI. 49% to 50% of patients currently on PPIs also reported having concerns with regards to long-term treatment. 70% of patients recalled being well informed on dosage and treatment regimens. However, other safety and usage information was reported as being less frequently discussed.Conclusions:Although patients reported concerns regarding ongoing long-term PPI treatment, this was not reflected in the prescribing pattern from physicians. More can be done to ensure patients are fully informed about their PPI treatment at consultation. Findings also suggest a disconnect exists between standard treatment guidelines and prescribing patterns, as experienced by patients.

Proton pump inhibitors: misconceptions and proper prescribing practice.

The current review summarizes and attempts to place in proper perspective the past year's literature regarding purported adverse effects of proton pump inhibitors (PPIs). Although generally considered safe, physicians are inundated with retrospective database-driven epidemiologic studies, and meta-analyses on the same studies, claiming a panoply of serious adverse effects associated with long-term use of PPIs. The quality of the evidence underlying most of these associations is very low and cannot ascribe cause and effect. Nonetheless, these reports have stoked fears, in both prescribers and patients. As a result, patients are being harmed. Physicians are not prescribing PPIs when medically indicated and patients are stopping PPIs without consulting their caregivers. It is reassuring that a cross-sectional analysis of data from the National Ambulatory Medical Care Survey as well as a double-blinded, placebo-controlled trial report no safety concerns with PPIs, other than a possible small association with enteric infection. Most of the publicized serious putative adverse effects attributed to PPIs have been debunked in more recent and properly designed studies. Nevertheless, PPIs should be prescribed for valid indications and, when prescribed long-term, they should be used at the lowest effective dose and their ongoing need periodically assessed.

A questionnaire on prescription patterns of proton pump inhibitors for hemodialysis patients in Japan

Proton pump inhibitors (PPIs) are widely used in the general population often without an endpoint. The practice of prescribing PPIs in the hemodialysis (HD) population is unknown. Thus, we aimed to identify the practice pattern related to PPI prescription for HD patients in Japan through a questionnaire survey. We conducted a questionnaire survey for physicians engaged in dialysis practice through email. An email was sent to physicians listed in the Japanese Society of Nephrology (JSN) and iHOPE International registry. We received 187 physicians' answers. One-hundred twelve (60%) physicians would prefer to continuously prescribe PPIs after 8weeks of treatment for peptic ulcer (PU) or gastroesophageal reflux disease (GERD). The main reason for continuous PPI prescription was the concern for recurrence of PU or GERD. Approximately 20% of physicians responded that they were not accustomed to de-prescribing PPIs for PU or GERD. The reason for PPI de-prescription was the concern for side effects or insurance adaptation period. Even in cases wherein PPIs were prescribed for uncertain reasons, 42% physicians would continuously prescribe PPIs. Most physicians (82%) who answered about stopping PPIs regarded HD patients as a high-risk group for PU. PPI prescription is often continued in HD patients. De-prescription is not a common practice in Japan. It remains unclear whether discontinuation of PPIs should be recommended in hemodialysis patients who have a high risk of gastrointestinal ulcer. Yet, considering the side effects and polypharmacy in the HD population, more discussions on preferable de-prescription of PPIs are needed.

Exacerbation of gastroesophageal reflux symptoms after discontinuation of proton pump inhibitors is not associated with increased esophageal acid exposure.

Discontinuation of long-term proton pump inhibitors (PPIs) on patients with reflux symptoms can be challenging, as symptoms often exacerbate after stopping. The mechanism remains unknown. Our aim was to evaluate the impact of stopping long-term PPIs on patients with heartburn, and its association with esophageal acid exposure. Patients with heartburn on long-term PPIs underwent symptom questionnaire, high-resolution manometry, and 24h ambulatory impedance-pH studies, following a 7-day PPIs discontinuation. We investigated the association between exacerbation of symptoms and findings on ambulatory reflux studies. We studied 37 patients. After stopping PPIs, 27 patients (73%) had exacerbation of heartburn. Esophageal acid exposure time% (AET) in patients with exacerbation of heartburn was not significantly higher than in patients without (3.5% [1.3-9.7] vs 2.5% [1.3-8.7], NS). Fourteen of 27 patients with exacerbation had physiological AET (<4%) as compared with 6 of 10 patients with physiological AET (NS). All questioned symptoms (heartburn, regurgitation, epigastric discomfort/pain, bloating/belch) worsened after stopping PPIs (NS). Exacerbation of heartburn after discontinuation of PPIs does not appear to be due to increased esophageal acid exposure.

AKT answer relating to stopping proton pump inhibitors (PPIs)

AKT answer relating to stopping proton pump inhibitors (PPIs)

AKT question relating to stopping proton pump inhibitors (PPIs)

AKT question relating to stopping proton pump inhibitors (PPIs)

Patients' Perceptions of Proton Pump Inhibitor Risks and Attempts at Discontinuation: A National Survey.

Little is known about how reports on the adverse effects of proton pump inhibitors (PPIs) impact patients' perceptions of these drugs and medication use. We sought to determine patients' level of concern about PPI adverse effects and its association with attempts to discontinue these drugs. This study is an online survey of US adults who use PPIs for gastroesophageal reflux disease. Topics included awareness of and concern about PPI adverse effects, prior discussion with providers, and attempts to stop PPI because of concern about adverse effects. For the primary analysis, we used logistic regression to identify associations between having attempted to stop PPI and concern about PPI-related adverse effects, a provider's recommendation to stop, risk of upper gastrointestinal bleeding (UGIB), age, and gender. Among 755 patient participants, mean age was 49 years (s.d. 16), 71% were women, and 24% were at high risk of UGIB. Twenty percent of patients were able to write in ≥1 reported adverse effect, and 46% endorsed awareness of ≥1 adverse effect when presented with a list, most commonly chronic kidney disease (17%). Thirty-three percent of patients were slightly concerned, 32% somewhat concerned, and 14% extremely concerned about adverse effects. Twenty-four percent of patients had discussed PPI risks and benefits with a provider, and 9% had been recommended to stop. Thirty-nine percent had attempted to stop their PPI, most (83%) without a provider recommendation. Factors associated with an attempt at stopping PPI included: (i) provider recommendation to stop (odds ratio [OR] 3.26 [1.82-5.83]); (ii) concern about adverse effects (OR 5.13 [2.77-9.51] for slightly, 12.0 [6.51-22.2] for somewhat, and 19.4 [9.75-38.7] for extremely concerned); and (iii) female gender (OR 1.64 [1.12-2.39]). Patients at high risk of UGIB were as likely to have attempted to stop as others (OR 0.98 [0.66-1.44]). Concern about PPIs is common and strongly associated with attempts at discontinuation, even without a provider's recommendation. Notably, individuals at high risk of UGIB, who benefit from PPIs, were equally likely to have tried stopping PPIs as others. Providers should proactively discuss the risks and benefits of PPIs with their patients, who may otherwise make unwise decisions about PPI management on their own.

Tu1005 - Willingness to Stop Proton Pump Inhibitors in Patients with Gastroesophageal Reflux Disease: Results of a Patient Survey

Tu1005 - Willingness to Stop Proton Pump Inhibitors in Patients with Gastroesophageal Reflux Disease: Results of a Patient Survey

Diagnosis of Zollinger-Ellison syndrome in the era of PPIs, faulty gastrin assays, sensitive imaging and limited access to acid secretory testing.

In recent years the diagnosis of Zollinger-Ellison syndrome (ZES) has become increasingly controversial with several new approaches and criteria proposed, differing from the classical biochemical criterion of inappropriate hypergastrinemia (i.e., hypergastrinemia in the presence of hyperchlorhydria) (Table 1). These changes have come about because of the difficulty and potential dangers of stopping proton pump inhibitors (PPIs) for gastric acid analysis; the recognition than many of the current assays used to assess gastrin concentrations are unreliable; the development of sensitive imaging modalities that detect neuroendocrine tumors (NETs) including an increasing number of the primary gastrinomas; the increased use of percutaneous or endoscopic ultrasound (EUS)-directed biopsies/cytology and the general lack of availability of acid secretory testing. In this article we will discuss the basis for these controversies, review the proposed changes in diagnostic approaches and make recommendations for supporting the diagnosis of ZES in the modern era.

Gastroesophageal reflux disease-related symptom recurrence in patients discontinuing proton pump inhibitors for Bravo® wireless esophageal pH monitoring study.

Patients with gastroesophageal reflux disease (GERD) are treated with proton pump inhibitors (PPIs). Those that do not achieve symptom relief, or non-responders, usually undergo esophageal pH monitoring off PPIs in order to confirm the presence of GERD. To assess the efficacy of the reverse-PPI trial in evaluating the presence of GERD or its recurrence rates, as well as to identify a correlation between the symptom recurrence rates and GERD severity determined by 48-hour Bravo® esophageal pH-monitor testing. A final total of 205 patients that underwent the 48-hour Bravo® esophageal pH-monitoring study were retrospectively included. Patients discontinued PPI usage for at least 7 days prior to testing, and completed symptom questionnaires during the 2-day test. The Bravo® test was considered positive if the percentage of time with esophageal pH <4 was >4.4%. A total of 363 patients underwent 48-hour Bravo® testing and of those patients, 205 were eligible for the study. Ninety-two patients reported symptoms as being «same/better» and 113 as being «worse» after stopping PPIs. Of the 92 patients with improved symptoms, 44 (48%) had documented acid reflux during the Bravo® study, compared with 65 of 113 (58%) patients with worsening symptoms that also complained of acid reflux. Of the 109 patients found to have confirmed GERD upon pH monitoring, 65 (59.6%) reported a worsening of symptoms, compared with 48 of 96 (50.0%) patients without GERD (p=0.043). Main symptoms stated to be worse included heartburn, chest pain, regurgitation, nausea, and belching (p<0.05). Of the 205 patients, 103 were off PPIs for 7 days. Seventy-two of them (68.9%) reported a worsening of symptoms, compared with 40 of the 102 (41.2%) patients that were off PPIs for>7 days (p=0.042) CONCLUSION: Symptom exacerbation following PPI cessation for at least 7 days correlated with acid reflux severity assessed by Bravo® testing. Patients off PPIs for 7 days had a higher likelihood of experiencing worsening symptoms, compared with those off PPIs for more than 7 days. These findings suggest that when PPIs are held for 7 days or less prior to Bravo® testing, acute worsening of upper GI symptoms due to the abrupt discontinuation of therapy may influence the Bravo® results. The etiology of this may be related to rebound acid hypersecretion and needs to be further elucidated in future studies.

Clostridium difficile (CD) Action Team (CDAT): An Intervention to Improve Care for Patients with a Positive CD PCR

BackgroundCD infections (CDI) may be viewed by healthcare workers (HCW) as an unpreventable consequence of antibiotics (abx). The purpose of CDAT was to use patient cases in real time to educate HCW on CD diagnostic, treatment and prevention practices including appropriate abx and proton-pump inhibitors (PPI) use.MethodsFrom 7/17/16 to 5/6/17, Johns Hopkins abx stewardship team reviewed positive CD PCRs in inpatient to determine whether they had CDI or colonization (no diarrhea or an alternate cause) and if prevention and management was optimal. Included in this time are 2 surveillance periods (SP) (SP1: 7/17–9/27/16 and SP2: 12/18/16–3/30/17). During SP1, there was no contact with HCW. SP2 followed the intervention, and allowed assessment of sustained practice changes. During the intervention periods (IP) (IP1: 10/9–12/17/16 and IP2: 3/31–5/6/17), teaching points for optimizing care for each case were shared and discussed in person with the HCW team, including prescribers and nursing. Compliance with recommendations at 48 hours was assessed. Chi-square test was used to compare sub-optimal management for each variable in different time periods.ResultsWe assessed 217 cases in the SPs and 96 cases in the IPs. 75 of 96 cases reviewed in the IPs required intervention. CDAT spoke to 74 teams, which led to a change in the care of patients in 49 cases (65%). Compliance with recommendations were as follows: 1) stop or modify CDI therapy, 53%, (39 cases); 2) stop PPI therapy, 52% (15 cases); 3) stop laxatives, 53% (9 cases); 4) stop or modify non-CDI abx, 46% (16 cases); and 5) improve BM documentation, 58% (11 cases). The Figure shows proportions of patients with suboptimal CD management without (SPs) or before (IPs) CDAT intervention in each period. There were no changes in practice between the SP1 and IP1. Between the SP1 and IP2, significant improvement in BM documentation was seen (P = 0.007). No differences were observed for other variables, although there was a trend towards improved CD therapy (P = 0.09).ConclusionOverall, prescribers did not independently change practice as a result of daily contact with CDAT; however, they were responsive to CDAT recommendations. BM documentation, the only nursing intervention, improved significantly.Disclosures All authors: No reported disclosures.

Gastroesophageal reflux disease-related symptom recurrence in patients discontinuing proton pump inhibitors for Bravo wireless esophageal pH monitoring study

BackgroundPatients with gastroesophageal reflux disease (GERD) are treated with proton pump inhibitors (PPIs). Those that do not achieve symptom relief, or non-responders, usually undergo esophageal pH monitoring off PPIs in order to confirm the presence of GERD. AimsTo assess the efficacy of the reverse-PPI trial in evaluating the presence of GERD or its recurrence rates, as well as to identify a correlation between the symptom recurrence rates and GERD severity determined by 48-hour Bravo esophageal pH-monitor testing. MethodsA final total of 205 patients that underwent the 48-hour Bravo esophageal pH-monitoring study were retrospectively included. Patients discontinued PPI usage for at least 7 days prior to testing, and completed symptom questionnaires during the 2-day test. The Bravo test was considered positive if the percentage of time with esophageal pH <4 was >4.4%. ResultsA total of 363 patients underwent 48-hour Bravo testing and of those patients, 205 were eligible for the study. Ninety-two patients reported symptoms as being «same/better» and 113 as being «worse» after stopping PPIs. Of the 92 patients with improved symptoms, 44 (48%) had documented acid reflux during the Bravo study, compared with 65 of 113 (58%) patients with worsening symptoms that also complained of acid reflux. Of the 109 patients found to have confirmed GERD upon pH monitoring, 65 (59.6%) reported a worsening of symptoms, compared with 48 of 96 (50.0%) patients without GERD (p=0.043). Main symptoms stated to be worse included heartburn, chest pain, regurgitation, nausea, and belching (p<0.05). Of the 205 patients, 103 were off PPIs for 7 days. Seventy-two of them (68.9%) reported a worsening of symptoms, compared with 40 of the 102 (41.2%) patients that were off PPIs for>7 days (p=0.042) ConclusionSymptom exacerbation following PPI cessation for at least 7 days correlated with acid reflux severity assessed by Bravo testing. Patients off PPIs for 7 days had a higher likelihood of experiencing worsening symptoms, compared with those off PPIs for more than 7 days. These findings suggest that when PPIs are held for 7 days or less prior to Bravo testing, acute worsening of upper GI symptoms due to the abrupt discontinuation of therapy may influence the Bravo results. The etiology of this may be related to rebound acid hypersecretion and needs to be further elucidated in future studies.

Deprescribing versus continuation of chronic proton pump inhibitor use in adults.

Proton pump inhibitors (PPIs) are a class of medications that reduce acid secretion and are used for treating many conditions such as gastroesophageal reflux disease (GERD), dyspepsia, reflux esophagitis, peptic ulcer disease, and hypersecretory conditions (e.g. Zollinger-Ellison syndrome), and as part of the eradication therapy for Helicobacter pylori bacteria. However, approximately 25% to 70% of people are prescribed a PPI inappropriately. Chronic PPI use without reassessment contributes to polypharmacy and puts people at risk of experiencing drug interactions and adverse events (e.g. Clostridium difficile infection, pneumonia, hypomagnesaemia, and fractures). To determine the effects (benefits and harms) associated with deprescribing long-term PPI therapy in adults, compared to chronic daily use (28 days or greater). We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 10), MEDLINE, Embase, clinicaltrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). The last date of search was November 2016. We handsearched the reference lists of relevant studies. We screened 2357 articles (2317 identified through search strategy, 40 through other resources). Of these articles, we assessed 89 for eligibility. We included randomized controlled trials (RCTs) and quasi-randomized trials comparing at least one deprescribing modality (e.g. stopping PPI or reducing PPI) with a control consisting of no change in continuous daily PPI use in adult chronic users. Outcomes of interest were: change in gastrointestinal (GI) symptoms, drug burden/PPI use, cost/resource use, negative and positive drug withdrawal events, and participant satisfaction. Two review authors independently reviewed and extracted data and completed the risk of bias assessment. A third review author independently confirmed risk of bias assessment. We used Review Manager 5 software for data analysis. We contacted study authors if there was missing information. The review included six trials (n = 1758). Trial participants were aged 48 to 57 years, except for one trial that had a mean age of 73 years. All participants were from the outpatient setting and had either nonerosive reflux disease or milder grades of esophagitis (LA grade A or B). Five trials investigated on-demand deprescribing and one trial examined abrupt discontinuation. There was low quality evidence that on-demand use of PPI may increase risk of 'lack of symptom control' compared with continuous PPI use (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.31 to 2.21), thereby favoring continuous PPI use (five trials, n = 1653). There was a clinically significant reduction in 'drug burden', measured as PPI pill use per week with on-demand therapy (mean difference (MD) -3.79, 95% CI -4.73 to -2.84), favoring deprescribing based on moderate quality evidence (four trials, n = 1152). There was also low quality evidence that on-demand PPI use may be associated with reduced participant satisfaction compared with continuous PPI use. None of the included studies reported cost/resource use or positive drug withdrawal effects. In people with mild GERD, on-demand deprescribing may lead to an increase in GI symptoms (e.g. dyspepsia, regurgitation) and probably a reduction in pill burden. There was a decline in participant satisfaction, although heterogeneity was high. There were insufficient data to make a conclusion regarding long-term benefits and harms of PPI discontinuation, although two trials (one on-demand trial and one abrupt discontinuation trial) reported endoscopic findings in their intervention groups at study end.

Association of Acute Gastroesophageal Reflux Disease With Esophageal Histologic Changes.

The histologic changes associated with acute gastroesophageal reflux disease (GERD) have not been studied prospectively in humans. Recent studies in animals have challenged the traditional notion that reflux esophagitis develops when esophageal surface epithelial cells are exposed to lethal chemical injury from refluxed acid. To evaluate histologic features of esophageal inflammation in acute GERD to study its pathogenesis. Patients from the Dallas Veterans Affairs Medical Center who had reflux esophagitis successfully treated with proton pump inhibitors (PPIs) began 24-hour esophageal pH and impedance monitoring and esophagoscopy (including confocal laser endomicroscopy [CLE]) with biopsies from noneroded areas of distal esophagus at baseline (taking PPIs) and at 1 week and 2 weeks after stopping the PPI medication. Enrollment began May 2013 and follow-up ended July 2015. PPIs stopped for 2 weeks. Twelve patients (men, 11; mean age, 57.6 year [SD, 13.1]) completed the study. Primary outcome was change in esophageal inflammation 2 weeks after stopping the PPI medication, determined by comparing lymphocyte, eosinophil, and neutrophil infiltrates (each scored on a 0-3 scale) in esophageal biopsies. Also evaluated were changes in epithelial basal cell and papillary hyperplasia, surface erosions, intercellular space width, endoscopic grade of esophagitis, esophageal acid exposure, and mucosal impedance (an index of mucosal integrity). At 1 week and 2 weeks after discontinuation of PPIs, biopsies showed significant increases in intraepithelial lymphocytes, which were predominantly T cells (median [range]: 0 (0-2) at baseline vs 1 (1-2) at both 1 week [P = .005] and 2 weeks [P = .002]); neutrophils and eosinophils were few or absent. Biopsies also showed widening of intercellular spaces (confirmed by CLE), and basal cell and papillary hyperplasia developed without surface erosions. Two weeks after stopping the PPI medication, esophageal acid exposure increased (median: 1.2% at baseline to 17.8% at 2 weeks; Δ, 16.2% [95% CI, 4.4%-26.5%], P = .005), mucosal impedance decreased (mean: 2671.3 Ω at baseline to 1508.4 Ω at 2 weeks; Δ, 1162.9 Ω [95% CI, 629.9-1695.9], P = .001), and all patients had evidence of esophagitis. In this preliminary study of 12 patients with severe reflux esophagitis successfully treated with PPI therapy, stopping PPI medication was associated with T lymphocyte-predominant esophageal inflammation and basal cell and papillary hyperplasia without loss of surface cells. If replicated, these findings suggest that the pathogenesis of reflux esophagitis may be cytokine-mediated rather than the result of chemical injury. clinicaltrials.gov Identifier: NCT01733810.

Management of patients with high output stomas and enterocutaneous fistulae: Do proton pump inhibitors really help?

Summary Background and aims Patients with high output stomas and enterocutaneous fistulae are prone to fluid and electrolyte abnormalities, particularly dehydration, hyponatraemia and hypomagnesaemia. As well as medication to prolong transit time and aid absorption, proton pump inhibitors (PPIs) have been advocated to reduce gastrointestinal losses. Recent, reports in other clinical areas have linked long-term PPI use to hypomagnesaemia. We wondered whether PPIs used to reduce stoma losses may paradoxically be aggravating hypomagnesaemia in these patients? Our aim was to audit the effect of stopping PPIs, used solely for reduction of gastrointestinal losses, in a cohort of patients with high stoma losses. Methods Nine patients (8 high output stomas: 1 enterocutaneous fistula) were regularly attending a dedicated clinic for supervision and management of fluid and electrolytes during October 2012. Stoma outputs, blood and urine results were recorded before and after stopping their PPI. Results There was a significant reduction in average daily stoma outputs when the PPI was stopped. Before PPI cessation, mean daily stoma volume was 1550 mls (SE:147.67) compared to mean of 1344 mls after (SE:130.29, t(8) = 2.11, p Conclusion Our findings do not support current thinking with regard to PPIs reducing enteric losses in patients with high stoma losses. The PPI effect on hypomagnesaemia in this cohort is uncertain but cessation should be considered in resistant hypomagnesaemia.

PTH-027 Stopping Proton Pump Inhibitors to Prevent Clostridium Difficile: Is it Possible and Does it Help?

IntroductionHypochlorhydydria due to proton pump inhibitor (PPI) therapy is associated with increased susceptibility and propensity to relapse from infection due to C difficile. The Health Protection Agency guidance advises review...