Chemical colitis due to endoscope cleaning solutions: a mimic of pseudomembranous colitis

Endoscope-induced colitis: description, probable cause by glutaraldehyde, and prevention

Six cases of acute, self-limited colitis that occurred after screening flexible sigmoidoscopy were deduced to be iatrogenic, probably caused by glutaraldehyde residues in the endoscopes after disinfection in an automatic disinfecting machine. The concentration of these residues was indirectly estimated by conductivity measurements of electrolyte concentration in the rinse-water tank of the disinfecting machine during and after five cycles and also in fluid remaining on the surface of the endoscopes and in the endoscope channels. After five cycles, residues in both the rinse water and fluid in the endoscope channels contained the equivalent of 0.2% glutaraldehyde. This was the result of a combination of technical and human errors. It can be prevented by changing the rinse water after each cycle, using forced air to dry the instruments, and washing the endoscopes before use. Users of the automatic disinfecting machine should be aware of the potential accumulation of toxic levels of residues that remain in endoscopes after disinfection.

Standardizing glutaraldehyde use in a regional group of ten major medical centers

The ICPs of 10 Southern California medical centers were able to coordinate efforts to standardize the use of glutaraldehyde for high-level disinfection. In implementing "APIC Guidelines for Selection and Use of Disinfectants," variations in practice similar to those recognized nationally were identified. Through coordinated efforts, the regional ICP group researched and developed a position paper to facilitate standardization of high-level disinfection practice.

Metabolism of trinitrobenzene sulfonic acid by the rat colon produces reactive oxygen species

Recent studies have shown that intrarectal administration of 2,4,6-trinitrobenzene sulfonic acid (TNBS) in ethanol or intramural injection of TNBS in saline produces an acute and possibly chronic colitis in rats. It has been assumed that interstitial TNBS initiates the inflammatory response via macrophage-mediated recognition and degradation of TNBS-modified mucosal cells and proteins. However, it is known that certain flavoproteins and/or reductants interact with compounds containing the nitro functional group to generate pro-inflammatory, nitrogen-centered free radicals and reactive oxygen metabolites. The objective of this study was to assess the ability of the rat colon, using either colon homogenates, isolated colonocytes, or intestinal interstitial fluid, to produce reactive oxygen species via enzymatic and/or nonenzymatic metabolism of TNBS. It was found that the addition of TNBS (1 mmol/L) to the 10,000 x g supernatant of rat colon homogenates increased the rate of superoxide production from normally undetectable levels to 2.6 +/- 0.23 nmol.min-1.mg protein-1. Addition of nicotinamide adenine dinucleotide, reduced form (NADH; 1 mmol/L) to colon homogenates containing TNBS significantly enhanced superoxide production to 10.4 +/- 0.9 nmol.min-1.mg-1. Similarly, addition of nicotinamide adenine dinucleotide phosphate, reduced form (NADPH; 1 mmol/L) to colon extracts containing TNBS produced an even further increase in the rate of superoxide formation to 25.2 +/- 1.1 nmol.min-1.mg-1. Addition of NADH or NADPH to the colon homogenate in the absence of TNBS produced no detectable superoxide formation, suggesting that TNBS was required for the enhanced oxidative metabolism. In a separate series of experiments, it was found that isolated colonocytes produced small but significant amounts of superoxide (3.15 +/- 0.6 nmol/2 x 10(6) cells) that were significantly increased in the presence of ethanol to 6.55 +/- 1.14 nmol/2 x 10(6) cells. Using purified preparations of two flavoproteins found in the rat colon, it was shown that the addition of TNBS (1 mmol/L) to purified NADH dehydrogenase or glutathione reductase increased the rate of superoxide formation by these enzymes from normally undetectable levels to 1.6 nmol/min and 1.2 nmol/min, respectively. In addition, it was found that intestinal interstitial fluid (lymph) initiated redox cycling of TNBS such that 28.1 +/- 1.6 nmol of oxygen was consumed per minute per milliliter of lymph. This increase in oxygen consumption was inhibited by the addition of superoxide dismutase and catalase. One possible metabolite involved in both mucosal and lymph-mediated metabolism of TNBS is ascorbic acid.(ABSTRACT TRUNCATED AT 400 WORDS)

Hydrogen peroxide enteritis: the "snow white" sign

Hydrogen peroxide is a useful disinfectant that has achieved widespread utility in varied clinical settings. We report an epidemic of hydrogen peroxide enteritis that developed in seven patients in our gastrointestinal endoscopy unit during a 2-week period in early 1988. During endoscopy, using recently sterilized endoscopes that were flushed with 3% hydrogen peroxide after the glutaraldehyde cycle, instantaneous blanching (the "snow white" sign) and effervescence were noted on the mucosal surfaces when the water button was depressed. No patient subsequently suffered morbidity or mortality associated with this peroxide enteritis, and the biopsy specimens revealed nonspecific inflammation. The toxicity of hydrogen peroxide when used in enema form is reviewed, as well as the pathogenesis of peroxide enteritis.