Proton pump inhibitors might be associated to an increased risk of Cholangitis in biliary-stented patients

BACKROUND: Endoscopic biliary endoprothesis insertion is the most common palliative treatment of biliary obstruction caused by benign strictures or malignant hepatobiliary tumors. The occlusion of the stents resulting in jaundice with or without cholangitis requires the regular removal and replacement of these stents. The occlusion results mainly from the biliary sludge occlusion and bacterial biofilm growth in the stent's lumen. Some data show that the widely used proton pump inhibitors change the spectrum and number of biliary pathogens in patients with acute cholangitis. AIM: Our goal was to investigate the relationship between acute cholangitis and the use of proton pump inhibitors in patients who underwent plastic biliary stenting because of malignant or benign strictures. Methods: In this retrospetive study, we searched the endoscopic database of our Institute for patients suffering from biliary stent occlusion in the period of 01.01.2008. to 31.12.2014. Patients with both benign and malignant strictures have been included and data on proton pump inhibitor intake, acute cholangitis were collected. The time period between the former plastic stent insertion and the actual endoscopic investigation was also investigated. Results: In the investigated timeframe of 7 years, a total number of 220 patients were treated in our Endoscopic Unit suffering from biliary stent occlusion and jaundice. 65 from these patients suffered from acute cholangitis as well. We found a significantly higher incidence of cholangitis in patients taking proton pump inhibitors (p < 0.0001) and a significantly increased incidence of cholangitis (p < 0.0001) was shown in patients suffering from malignant strictures, as well. Conclusion: The use of proton pump inhibitors seems to increase the risk of cholangitis in biliary stented patients. The reduced acid production may contribute the bacterial overgrowth in the stent's lumen and in the small bowel as well. In patients with malignant strictures the compromised activity of the immune system may be related to the major incidence of cholangitis.