Sipping on my coffee this morning, I felt a touch of heartburn (pyrosis) which brought Proton Pump inhibitors (PPIs) to mind. They have been a blessing for GERD, dyspepsia, upper GI bleeds etc. and are one of the most widely used medications on the face of Earth. Their effectiveness in curtailing gastric acidity is truly impressive !
Another important effect of PPIs, not as well known, is a significant reduction of overall gastric juice secretion volumes. This volume reduction plays a vital role in the ability of PPIs in controlling reflux symptoms – less gastric stretch makes for a more effective gastroesophageal sphincter. Multiple randomized controlled trials such as these from 2008 (ICU patients) , 2015 (normal v/s GERD patients) have demonstrated effective reduction in post-PPI gastric volumes. This 2018 case report published in UCLA Proceedings of Health, showed NG output in a bowel obstruction patient dropping from 2.5 lites a day to 200 cc after starting IV Protonix with resolution of obstruction !
This effect perhaps needs to be exploited more often. Our little stomach unbelievably secretes 1.5 – 2.5 liters a day that is absorbed downstream. In conditions mentioned below, this volume can build-up fast, expand the gastric wall and worsen nausea & emesis. In addition, in bowel obstructions, the flood of fluid can also dilate intestinal walls, compromise venous & lymphatic return & delay resolution. In the following situations, I like to use short-term high dose PPIs twice a day IV:
- Ileus
- Partial or complete bowel obstruction : Early use of PPIs in these cases could avoid or help faster removal of NG tube
- Inoperable / Malignant bowel obstructions, like the case report mentioned above.
- Gastritis from any cause like alcohol, overdose
- Acute Gastroparesis exacerbation
- Critically sick, encephalopathic patients at risk of reflux related aspiration
- Consistently high liquid stool output from a ileostomy causing risk of dehydration
💡 PS: I am NOT advocating excessive or long term use of Proton Pump Inhibitors. Gastric secretion volumes have important roles in aiding digestion, lubrication & transport of luminal contents downstream. I only suggest short term use of high doses in the situations mentioned in this post, unless for palliative reasons such a malignant, inoperable bowel obstruction.
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