Mo1313 Use of Proton Pump Inhibitors (PPIs) is Associated With a Need for More Subsequent Biliary Drainage Procedures in Patients With Malignant Biliary Strictures Treated With a Self-Expanding Metal Stent (SEMS)

Use of Proton Pump Inhibitors (PPIs) is Associated With a Need for More Subsequent Biliary Drainage Procedures in Patients With Malignant Biliary Strictures Treated With a Self-Expanding Metal Stent (SEMS) Neil Gupta*, Christine E. Hovis, Thomas G. Hollander, Sachin Wani, Faris Murad, Riad R. Azar, Sreenivasa S. Jonnalagadda, Steven A. Edmundowicz, Daniel Mullady Washington University in St. Louis, St. Louis, MO Background: In patients with advanced malignancy, the role of SEMS placement is to provide patency of the biliary tree for the duration of the patient’s limited life span. Several factors including microbial colonization, tissue hyperplasia, and tumor ingrowth have been hypothesized to cause biliary endoprothesis occlusion. While PPIs can alter the normal gastroduodenal acid physiology and may lead to small bowel bacterial overgrowth, it is unknown whether this can result promote biliary SEMS occlusion. Aim: To determine whether PPI use is associated with the recurrent biliary obstruction in patients with malignant biliary strictures treated with a SEMS. Methods: Retrospective cohort study of patients undergoing endoscopic retrograde cholangiopancreatography at a single tertiary referral center between 9/2004 and 6/2010. Data was obtained from a prospectively maintained endoscopic database. Patients with a malignant biliary stricture who underwent placement of their first biliary SEMS were included in the analysis. The electronic medal record for each included patient was reviewed to determine demographic information, past medical history (PPI use, prior cholecystectomy, prior biliary sphincterotomy, prior plastic biliary endoprosthesis placement), and endoscopic details. Study outcomes included the development of cholangitis, endoscopically visible SEMS occlusion, and the need for repeat ERCPs with or without placement of another biliary endoprothesis for other symptoms/signs of recurrent biliary obstruction. Patients using and not using PPIs were compared using Fisher’s exact test and the Wilcoxon-rank sum test for categorical and continuous variables, respectively. Results: 150 patients met the study inclusion/exclusion criteria: 73 using PPIs and 77 not using PPIs. There was no difference between patients using and not using PPI with regards to age, gender, history of cholecystectomy, history of prior plastic biliary endoprosthesis placement, location of biliary stricture, and biliary sphincterotomy. There was no difference between the two groups with regards to the diameter, length, type, and number of SEMS placed. Patients using PPIs were more likely to require a repeat ERCP, repeat endoprosthesis placement, and repeat endoprosthesis placement in 6 months, while there was no difference in the rate of cholangitis or endoscopically visible SEMS occlusion. (Table) Discussion: PPI use is associated with a need for more frequent ERCPs and repeat biliary endoprosthesis placement in patients with malignant biliary strictures initially treated with SEMS placement. Pending confirmation in future studies, patients should be re-evaluated to ensure judicious use of PPIs, as this may reduce the need for repeat invasive procedures in this population.