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Jia Y, Dwivedi A, Elhanafi S, Ortiz A, Othman M, Zuckerman M. Low risk of bacteremia after endoscopic variceal therapy for esophageal varices: a systematic review and meta-analysis. Endosc Int Open 2015; 3:E409-17. [PMID: 26528494 PMCID: PMC4612236 DOI: 10.1055/s-0034-1392552] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 05/07/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic variceal ligation (EVL) and endoscopic variceal sclerotherapy (EVS) are the main therapeutic procedures for the emergency treatment and secondary prophylaxis of esophageal varices in cirrhotics. Post-endoscopic bacteremia has been reported after EVS and EVL, but data on the frequency of bacteremia are conflicting. This study aims to provide incidences of bacteremia after EVS and EVL in different settings through meta-analysis. METHODS Only prospective or randomized studies were included in this meta-analysis. Binomial distribution was used to compute variance for each study. Random effects models were used as the final model for estimating the effect size and 95 % confidence interval. Adjusted effects were obtained using meta-regression analysis. RESULTS Nineteen prospective studies involving 1001 procedures in 587 patients were included in the meta-analysis on the risk of bacteremia after EVS or EVL in cirrhotics with esophageal varices. The frequency of bacteremia after endoscopic variceal therapy was 13 %. The frequency of bacteremia after EVS (17 %) was higher than after EVL (6 %) with no statistically significant difference (P = 0.106). The frequency of bacteremia after elective EVS (14 %) was significantly less than after emergency EVS (22 %) (P < 0.001). The frequency of bacteremia after elective EVL (7.6 %) was not significantly different from after emergency EVL (3.2 %) (P = 0.850). CONCLUSIONS The incidence of bacteremia is low in patients with cirrhosis and varices after esophageal variceal therapy. These results are consistent with our current guidelines that antibiotic prophylaxis before endoscopic variceal therapy is only necessary for bleeding patients.
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Affiliation(s)
- Yi Jia
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Alok Dwivedi
- Division of Biostatistics & Epidemiology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Sherif Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Arleen Ortiz
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Mohamed Othman
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Marc Zuckerman
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA,Corresponding author Marc J. Zuckerman, MD Division of GastroenterologyTexas Tech University Health Sciences Center4800 Alberta AvenueEl PasoTexas 79905USA+1-915-545-6634
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Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy. Clin Microbiol Rev 2013; 26:231-54. [PMID: 23554415 DOI: 10.1128/cmr.00085-12] [Citation(s) in RCA: 294] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Flexible endoscopy is a widely used diagnostic and therapeutic procedure. Contaminated endoscopes are the medical devices frequently associated with outbreaks of health care-associated infections. Accurate reprocessing of flexible endoscopes involves cleaning and high-level disinfection followed by rinsing and drying before storage. Most contemporary flexible endoscopes cannot be heat sterilized and are designed with multiple channels, which are difficult to clean and disinfect. The ability of bacteria to form biofilms on the inner channel surfaces can contribute to failure of the decontamination process. Implementation of microbiological surveillance of endoscope reprocessing is appropriate to detect early colonization and biofilm formation in the endoscope and to prevent contamination and infection in patients after endoscopic procedures. This review presents an overview of the infections and cross-contaminations related to flexible gastrointestinal endoscopy and bronchoscopy and illustrates the impact of biofilm on endoscope reprocessing and postendoscopic infection.
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Serafy ME, Mahmoud M, Gaber M. Pattern of bacteraemia following endoscopic elective oesophageal injection sclerotherapy and band ligation in cirrhotic patients. Arab J Gastroenterol 2010. [DOI: 10.1016/j.ajg.2010.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Shaukat A, Nelson DB. Risks of Infection from Gastrointestinal Endoscopy. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2007. [DOI: 10.1016/j.tgie.2007.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Weickert U, Vetter S, Burkhardt U, Eickhoff A, Bühl A, Riemann JF. Bacteremia after diagnostic conventional laparoscopy and minilaparoscopy: a prospective study in 100 patients. J Clin Gastroenterol 2006; 40:701-4. [PMID: 16940882 DOI: 10.1097/00004836-200609000-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND/GOALS Diagnostic laparoscopy under sedoanalgesia is a valuable tool in the work-up of liver diseases and is helpful as a staging procedure. The rate of bacteremia caused by this procedure is unknown, in particular when performed as minilaparoscopy. STUDY A 100 consecutive patients having undergone diagnostic laparoscopy carried out either conventionally (group I, n=50) or as minilaparoscopy (group II, n=50) were prospectively enrolled in this study. Blood cultures were drawn before and within 5 minutes after the procedure. Risk factors for bacteremia were evaluated. RESULTS Bacterial growth occurred in 4 blood cultures drawn immediately after laparoscopy. No patient developed fever or other signs of infection in the follow-up. Risk factors predisposing to bacteremia could not be identified. CONCLUSIONS Conventional diagnostic laparoscopy under sedoanalgesia and minilaparoscopy are associated with a low rate of bacteremia as in diagnostic upper endoscopy.
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Affiliation(s)
- Uwe Weickert
- Department of Internal Medicine C, Ludwigshafen Hospital, Academic Hospital of the University of Mainz, Germany.
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Krige JEJ, Shaw JM, Bornman PC. The Evolving Role of Endoscopic Treatment for Bleeding Esophageal Varices. World J Surg 2005; 29:966-73. [PMID: 15981047 DOI: 10.1007/s00268-005-0138-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The treatment of acute and recurrent variceal bleeding is best accomplished by a skilled, knowledgeable, and well-equipped team using a multidisciplinary integrated approach. Optimal management should provide the full spectrum of treatment options including pharmacologic therapy, endoscopic treatment, interventional radiologic procedures, surgical shunts, and liver transplantation. Endoscopic therapy with either band ligation or injection sclerotherapy is an integral component of the management of acute variceal bleeding and of the long-term treatment of patients after a variceal bleed. Variceal eradication with endoscopic ligation requires fewer endoscopic treatment sessions and causes substantially less esophageal complications than does injection sclerotherapy. Although the incidence of early gastrointestinal rebleeding is reduced by endoscopic ligation in most studies, there is no overall survival benefit relative to injection sclerotherapy. Simultaneous combined ligation and sclerotherapy confers no advantage over ligation alone. A sequential staged approach with initial endoscopic ligation followed by sclerotherapy when varices are small may prove to be the optimal method of reducing variceal recurrence. Overall, current data demonstrate clear advantages for using ligation in preference to sclerotherapy. Ligation should therefore be considered the endoscopic treatment of choice in the treatment of esophageal varices.
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Affiliation(s)
- J E J Krige
- Department of Surgery and Medical Research Council, Liver Research Center, University of Cape Town Health Sciences Faculty, Observatory, 7925 Cape Town, South Africa.
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Wahl P, Lammer F, Conen D, Schlumpf R, Bock A. Septic complications after injection of N-butyl-2-cyanoacrylate: report of two cases and review. Gastrointest Endosc 2004; 59:911-6. [PMID: 15173814 DOI: 10.1016/s0016-5107(04)00341-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Peter Wahl
- Department of Surgery, Kantonsspital, Aarau, Switzerland
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Janssen J, König K, Knop-Hammad V, Johanns W, Greiner L. Frequency of bacteremia after linear EUS of the upper GI tract with and without FNA. Gastrointest Endosc 2004; 59:339-44. [PMID: 14997128 DOI: 10.1016/s0016-5107(03)02707-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Few data are available concerning the frequency of bacteremia after diagnostic EUS or EUS-guided FNA. This study was undertaken to provide these data and to determine whether present guidelines for prophylactic administration of antibiotics to prevent endocarditis during upper endoscopy are applicable to EUS and EUS-guided FNA. METHODS A total of 100 patients who were to undergo diagnostic EUS of the upper-GI tract and 50 who were to have upper-GI EUS-guided FNA were enrolled in this prospective study. Blood cultures were obtained before and within 5 minutes after the conclusion of the procedure. In case of bacterial growth, patients were observed for at least 3 days for signs of infection. RESULTS After diagnostic EUS, significant bacteremia was found in two patients with esophageal carcinoma (2%: 95% CI[0%, 4.8%]) and after EUS-guided FNA in two patients (4%: 95% CI[0%, 9.6%]). The difference was not statistically significant. None of these patients developed clinical signs of infection. Risk factors predisposing to bacteremia could not be identified. CONCLUSION The frequency of bacteremia after EUS, with and without FNA, is within the range of that for diagnostic upper endoscopy. Therefore, the same recommendations for prophylactic administration of antibiotics to prevent endocarditis may be applied in patients undergoing EUS and EUS-guided FNA. The role of esophageal cancer as a predisposing factor to EUS-associated infection remains uncertain.
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Affiliation(s)
- Jan Janssen
- Department of Medicine 2 and the Institute for Microbiology and Immunology, HELIOS Klinikum Wuppertal, University of Witten/Herdecke, Wuppertal, Germany
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Affiliation(s)
- Douglas B Nelson
- Gastroenterology, Minneapolis VA Medical Center, Minnesota 55417, USA
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Nelson DB. Infection control during gastrointestinal endoscopy. THE JOURNAL OF LABORATORY AND CLINICAL MEDICINE 2003; 141:159-67. [PMID: 12624597 DOI: 10.1067/mlc.2003.24] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Infection-control issues during gastrointestinal endoscopy, which are becoming increasingly important, can generally be divided into three major areas: (1) infectious complications resulting from a patient's own microbial flora (autologous), (2) infections transmitted from patient to patient by way of the endoscope (exogenous), and (3) infections transmitted between the patient and the health-care provider. The mean frequency of postprocedure bacteremia ranges from 0.5% for flexible sigmoidoscopy to 2.2% for colonoscopy, 4.2% for esophagogastroduodenoscopy, 8.9% for variceal ligation, 11% for endoscopic retrograde cholangiopancreatography, 15.4% for variceal sclerotherapy, and 22.8% for esophageal dilation. Although postprocedure bacteremia is not uncommon, it seldom results in infectious complications. Exogenous infections transmitted during endoscopy, which are extremely rare, generally result from failure to follow accepted guidelines for the cleaning and disinfection of gastrointestinal endoscopes, underscoring the importance of meticulous attention to endoscope reprocessing. Finally, although the risk of patient-staff transmission of infection is also rare, standard infection-control recommendations are important in protecting both patients and health-care providers.
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Affiliation(s)
- Douglas B Nelson
- Department of Gastroenterology, Minneapolis Veterans Affairs Medical Center, University of Minnesota, 55417, USA.
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Nagamine N, Kaneko Y, Kumakura Y, Ogawa Y, Ido K, Kimura K. Occurrence of pyogenic meningitis during the course of endoscopic variceal ligation therapy. Gastrointest Endosc 1999; 49:110-3. [PMID: 9869735 DOI: 10.1016/s0016-5107(99)70457-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- N Nagamine
- Department of Gastroenterology, Jichi Medical School, Yamanashi-ken, Japan
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ZENDA T, MASUNAGA T, TAKEDA Y, MABUCHI H. Efficacy of Endoscopic Esophageal Variceal Ligation in an Immunocompromised Host. Dig Endosc 1996. [DOI: 10.1111/j.1443-1661.1996.tb00411.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Takahiro ZENDA
- Second Department of Internal Medicine, School of Medicine, Kanazawa University, Kanazawa, Japan
| | - Takaharu MASUNAGA
- Second Department of Internal Medicine, School of Medicine, Kanazawa University, Kanazawa, Japan
| | - Yasuo TAKEDA
- Second Department of Internal Medicine, School of Medicine, Kanazawa University, Kanazawa, Japan
| | - Hiroshi MABUCHI
- Second Department of Internal Medicine, School of Medicine, Kanazawa University, Kanazawa, Japan
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Bacteremia and bacterascites after endoscopic sclerotherapy for bleeding esophageal varices and prevention by intravenous vefotaxime: A randomized trial. Gastrointest Endosc 1994. [DOI: 10.1016/s0016-5107(94)70109-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
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Stiegmann GV, Goff JS, Michaletz-Onody PA, Korula J, Lieberman D, Saeed ZA, Reveille RM, Sun JH, Lowenstein SR. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices. N Engl J Med 1992; 326:1527-32. [PMID: 1579136 DOI: 10.1056/nejm199206043262304] [Citation(s) in RCA: 403] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Endoscopic sclerotherapy is an accepted treatment for bleeding esophageal varices, but it is associated with substantial local and systemic complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, may be safer. We compared the effectiveness and safety of the two techniques. METHODS In this randomized trial we compared endoscopic sclerotherapy and endoscopic ligation in 129 patients with cirrhosis who had proved bleeding from esophageal varices. Sixty-five patients were treated with sclerotherapy, and 64 with ligation. Initial treatment for acute bleeding was followed by elective retreatment to eradicate varices. The patients were followed for a mean of 10 months, during which we determined the incidence of complications and recurrences of bleeding, the number of treatments needed to eradicate varices, and survival. RESULTS Active bleeding at the first treatment was controlled by sclerotherapy in 10 of 13 patients (77 percent) and by ligation in 12 of 14 patients (86 percent). Slightly more sclerotherapy-treated patients had recurrent hemorrhage during the study (48 percent vs. 36 percent for the ligation-treated patients, P = 0.072). The eradication of varices required a lower mean (+/- SD) number of treatments with ligation (4 +/- 2 vs. 5 +/- 2, P = 0.056) than with sclerotherapy. The mortality rate was significantly higher in the sclerotherapy group (45 percent vs. 28 percent, P = 0.041), as was the rate of complications (22 percent vs. 2 percent, P less than 0.001). The complications of sclerotherapy were predominantly esophageal strictures, pneumonias, and other infections. CONCLUSIONS Patients with cirrhosis who have bleeding esophageal varices have fewer treatment-related complications and better survival rates when they are treated by esophageal ligation than when they are treated by sclerotherapy.
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Affiliation(s)
- G V Stiegmann
- Department of Surgery, University of Colorado, Denver
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Abstract
Variceal bleeding has a high mortality, as the majority of patients have cirrhosis, with hepatic coma, renal failure, ascites and clotting deficiencies as complicating factors. Bleeding varices must therefore be treated as an emergency. Resuscitation, endoscopic diagnosis and haemostasis are the cornerstones of treatment. Once bleeding varices have been identified, attempts to stop the bleeding must be made at once as this will lessen the chances of hepatic failure developing. Endoscopic sclerotherapy at the time of diagnosis is the best available treatment at present, although profusely bleeding varices can be difficult to see and inject. In these circumstances the passage of a Sengstaken tube should stop the bleeding, allowing later sclerotherapy to be successful. If rebleeding recurs and cannot be controlled, oesophageal transection with a stapling gun may be life-saving, although the varices may later recur and long-term endoscopic follow-up will be necessary. Portacaval shunting and the distal splenorenal shunt involve arduous surgery and are followed by a significant incidence of hepatic encephalopathy; they should be reserved for those few cases when simpler measures have failed, although shunts do lead to permanent decompression of the portal system. The acute variceal bleed may also be dealt with pharmacologically. Vasopressin, used in combination with nitroglycerin to lessen the harmful side-effects, is cheaper and as effective as terlipressin or somatostatin and its synthetic analogue octreotide. Several courses of injection sclerotherapy will be required to eliminate oesophageal varices. Thereafter, long-term follow-up will be necessary to deal with any recurrence. The place of non-selective beta-blockers is still contentious, but they do reduce portal pressure and may lessen the chance of rebleeding. There is also a growing role for hepatic transplantation, which not only eliminates the varices but also restores liver function to normal and greatly reduces the risk of subsequent hepatoma development.
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