Bacteriaemia associated with endoscopic sclerotherapy of oesophageal varices

Infections in Liver Transplantation

Liver transplantation has become an important treatment modality for patients with end-stage liver disease/cirrhosis, acute liver failure, and hepatocellular carcinoma. Although surgical techniques and immunosuppressive regimens for liver transplantation have improved significantly over the past 20 years, infectious complications continue to contribute to the morbidity and mortality in this patient population. The use of standardized screening protocols for both donors and recipients, coupled with targeted prophylaxis against specific pathogens, has helped to mitigate the risk of infection in liver transplant recipients. Patients with chronic liver disease and cirrhosis have immunological deficits that place them at increased risk for infection while awaiting liver transplantation. The patient undergoing liver transplantation is prone to develop healthcare-acquired infections due to multidrug-resistant organisms that could potentially affect patient outcomes after transplantation. The complex nature of liver transplant surgery that involves multiple vascular and hepatobiliary anastomoses further increases the risk of infection after liver transplantation. During the early post-transplantation period, healthcare-acquired bacterial and fungal infections are the most common types of infection encountered in liver transplant recipients. The period of maximal immunosuppression that occurs at 1–6 months after transplantation can be complicated by opportunistic infections due to both primary infection and reactivation of latent infection. Severe community-acquired infections can complicate the course of liver transplantation beyond 12 months after transplant surgery. This chapter provides an overview of liver transplantation including indications, donor-recipient selection criteria, surgical procedures, and immunosuppressive therapies. A focus on infections in patients with chronic liver disease/cirrhosis and an overview of the specific infectious complications in liver transplant recipients are presented.

A Prospective Randomized Study on the Risk of Bacteremia in Banding versus Sclerotherapy of Esophageal Varices

Background

Esophageal variceal banding may be less likely to cause bacteremia than sclerotherapy. The existing data about the frequency of bacteremia after esophageal variceal banding are conflicting, and few studies include both banding and sclerotherapy.

Aims

We conducted a prospective randomized controlled trial to compare the frequency of bacteremia after esophageal variceal banding and sclerotherapy.

Methods

Over a 2-year period, patients with liver disease admitted for upper gastrointestinal bleeding or for outpatient elective variceal therapy were enrolled. New patients were randomized preprocedure to either banding or sclerotherapy, and subsequent sessions utilized the initial procedure. The groups consisted of banding, sclerotherapy, and endoscopy without variceal therapy. Subjects underwent endoscopy by one out of three gastroenterologists. Blood cultures were obtained 5 min before and 30 min after endoscopy to check for bacteremia.

Results

Postendoscopic blood cultures were positive following 4 out of 139 (2.9%) sessions: 1 sclerotherapy and 3 control sessions. All postendoscopic positive blood cultures were found following emergency sessions (4/92, 4.3%). One pre-endoscopic blood culture was positive in a patient with emergency banding. The rates of positive postendoscopic blood cultures among groups with emergency banding (0/22, 0%), emergency sclerotherapy (1/41, 2.3%), and emergency control (3/29, 10.3%) were not significantly different. Postendoscopic positive blood cultures were not found after elective sessions with either banding or sclerotherapy.

Conclusions

Postendoscopic bacteremia was infrequent following emergency endoscopy in patients with esophageal variceal bleeding. Bacteremia was not found after esophageal variceal banding, although this was not significantly less frequent than after sclerotherapy. Postendoscopic bacteremia was not associated with elective variceal therapy.

Low risk of bacteremia after endoscopic variceal therapy for esophageal varices: a systematic review and meta-analysis

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.

Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy

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.

Endoscopic management of gastric varices: efficacy and outcomes of gluing with N-butyl-2-cyanoacrylate in a North American patient population

BACKGROUND

Gastric variceal bleeding is associated with significant morbidity and mortality in patients with portal hypertension. Outside of North America, gastric variceal injection of N-butyl-2-cyanoacrylate has been shown to be safe and effective. The majority of studies on this mode of therapy are in Asian populations in which the etiology of portal hypertension differs from North America.

AIM

To assess the safety and efficacy of gastric variceal glue injection in a North American population.

METHODS

Consecutive patients that underwent glue injection of gastric varices in the Calgary Health Region from 2001 to 2006 were assessed.

RESULTS

Thirty-four patients (19 men, 15 women) underwent a total of 47 separate gluing procedures. Of those presenting with active bleeding at endoscopy, immediate hemostasis was achieved in 93.8% of patients. Rebleeding within 48 h of gluing was observed after four procedures. Gastric varices were eradicated in 84.0% of cases. Complications included superior mesenteric vein thrombosis in one patient. Twenty-eight (82.4%) patients were alive at the end of follow-up. The treatment failure-related mortality rate was 2.1%.

CONCLUSIONS

The present study is one of the few to assess the role of gastric variceal gluing in a North American population. Glue injection with cyanoacrylate is safe and effective in the treatment of bleeding gastric varices.

Low frequency of bacteremia after an endoscopic resection for large colorectal tumors in spite of extensive submucosal exposure

BACKGROUND

During an EMR or endoscopic submucosal dissection (ESD) for colorectal tumors, an injection needle catheter is passed through the contaminated endoscopic channel and may directly inoculate bacteria into the blood stream during submucosal injection. In addition, extensively exposed submucosa, especially with an ESD, directly contacts colonic luminal bacteria after the procedure, which may increase the risk of bacteremia. However, the incidence of bacteremia after an EMR or ESD for colorectal tumors has not been reported.

OBJECTIVE

To evaluate the frequency of bacteremia associated with an EMR or ESD for colon lesions.

DESIGN

A prospective study.

PATIENTS

A total of 40 patients who underwent a conventional EMR (n = 30), an EMR after circumferential pre-cutting (n = 3), or ESD (n = 7) for colorectal tumors.

INTERVENTIONS AND MAIN OUTCOME MEASUREMENTS

Blood cultures were obtained immediately before, 5 minutes after, and 30 minutes after the procedure. Patients were closely monitored for 24 hours after the procedure to detect the development of infectious complications.

RESULTS

Blood cultures at baseline and 5 minutes after the procedure were all negative. However, a blood culture at 30 minutes after the procedure showed a positive result in 1 of 40 patients (2.5%). This patient underwent a conventional EMR, and the isolated microorganism was coagulase-negative Staphylococcus, which might be regarded as a contaminant. None of the 40 patients showed any signs or symptoms associated with infection.

LIMITATION

The small sample size.

CONCLUSIONS

An EMR, or even an ESD, for colon lesions may be considered a low-risk procedure for infectious complications that does not warrant prophylactic administration of antibiotics.

Bacteremia after diagnostic conventional laparoscopy and minilaparoscopy: a prospective study in 100 patients

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.

Bacteremia in cirrhotic patients submitted to endoscopic band ligation of esophageal varices

BACKGROUND

Endoscopic procedures can develop bacteremia. Patients with chronic liver disease are more predisposed to undergo bacteremia and infections because they are immunocompromised.

AIMS

The purpose of this study was to determine the incidence of bacteremia in cirrhotics submitted to endoscopic variceal ligation.

METHODS

Three groups of 40 patients each were studied. One group was made up of patients with cirrhosis who were submitted to ligation, a second group was composed of cirrhotics who underwent esophagogastroduodenoscopy only, and a third group was composed of patients without liver disease who underwent esophagogastroduodenoscopy. Blood was sampled from all patients for culture, both in aerobic and in anaerobic mediums, immediately before endoscopy and at 5 and 30 minutes after its completion.

RESULTS

Blood culture was positive in 6 samples. In 4 of these, the bacteria (Staphylococcus hominis hominis, Staphylococcus auricularis, Acinetobacter lwoffii, and coagulase-negative staphylococcus) were isolated before the endoscopic procedure and thus were considered as contamination. In the ligation group, a streptococcus of the viridans group was isolated 5 minutes after the procedure, and in the cirrhosis without ligation group, a Staphylococcus epidermidis was isolated at 30 minutes. None of the patients showed clinical evidence of infection.

CONCLUSIONS

The bacteremia incidence in cirrhotic patients submitted to variceal ligation was 2.5%, showing no difference from the control groups.

Native liver xanthogranulomatous cholangiopathy in primary sclerosing cholangitis: impact on posttransplant outcome

A retrospective analysis of 51 primary sclerosing cholangitis (PSC) patients who underwent liver transplant (LT) identified 16 with xanthogranulomatous cholangiopathy (XGC) at the native liver hilum. Pre-LT clinical and laboratory data and post-LT course and outcome of patients with XGC were compared with the 35 PSC patients without XGC. The XGC and non-XGC groups were similar with respect to age and laboratory data at the time of LT. Pre-LT cholecystectomy was performed in 44% versus 26% and biliary bypass procedure in 38% versus 26% of patients with and without XGC, respectively (P = NS). Peri-operative complications resulted in six (38%) deaths or retransplantation within 60 days of LT in the XGC group compared with 4 (11%) in the non-XGC group (P =.05). Patient survival at 60 and 100 days post-LT was better in the non-XGC group (P =.01). The causes of death or retransplantation within 60 days post-LT in the patients with XGC included primary nongraft function (1), uncontrolled bleeding (3), and sepsis (2), while in the non-XGC group these were uncontrolled bleeding (2), sepsis (1), and primary nongraft function (1). Mean graft survival +/- SD was 1,081 +/- 1,584 days in patients with XGC versus 2,149 +/- 1,679 days in patients without XGC. The presence of XGC in the native liver hilum of PSC patients undergoing LT was associated with a higher rate of early post-LT mortality or retransplantation. In conclusion, no pre-LT clinical features or laboratory tests were identified that predicted the presence of XGC in PSC patients.

Pleuropulmonary complications of esophageal variceal sclerotherapy with absolute alcohol

BACKGROUND

Esophageal variceal sclerotherapy (EVS) is an effective means of controlling variceal hemorrhage. However, it causes a wide variety of local and systemic complications. The present study was performed to document pleuropulmonary complications of EVS with absolute alcohol.

METHODS

Twenty-six patients of portal hypertension of different etiologies were subjected to EVS with absolute alcohol. Baseline arterial blood gas analysis (PaO2, PaCO2, pH, HCO3, SaO2), chest X-ray and pulmonary function tests (forced expiratory volume at 1 s (FEV1), forced expiratory vital capacity (FVC), FEV1/FVC, maximum mid-expiratory flow rate (MMFR), and peak expiratory flow rate (PEFR)) were performed 4-6 h before the first session of EVS. These investigations were repeated within 24 h of EVS. Patients were asked to maintain a symptom diary and to record symptoms such as fever, chest pain, dysphagia and dyspnea during the study period.

RESULTS

Ten patients (38.46%) had chest pain and four patients (15.68%) had fever after sclerotherapy. Eight patients (30.54%) complained of dyspnea and six patients (23.08%) developed pleural effusion. There was a significant decline in FVC and FEV1 after EVS as compared with baseline values. However, FEV1/FVC ratio, MMFR and PEFR did not have any significant change.

CONCLUSIONS

Chest pain (38.46%), dyspnea (30.54%) and fever (15.68%) were the common symptoms after EVS while chest X-ray showed pleural effusion in 23.08%. Pulmonary function tests revealed a significant decline in FEV1 and FVC without change in FEV1/FVC ratio after EVS, suggesting a restrictive type of defect.

Infection control during gastrointestinal endoscopy

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.

Bacterial peritonitis after elective endoscopic variceal ligation: a prospective study

OBJECTIVE

Endoscopic variceal ligation is becoming the therapy of choice for esophageal varices, replacing endoscopic variceal sclerotherapy. The latter is associated with a 5-53% incidence of port-procedural bacteremia and a 0.5-3% incidence of peritonitis, whereas the former carries a 3-6% risk of bacteremia. However, the incidence of peritonitis after variceal ligation has not been well studied. This prospective study is designed to investigate the risk of developing bacteremia and bacterial peritonitis after elective endoscopic variceal ligation.

METHODS

Sixty-seven patients with esophageal varices and ascites secondary to liver cirrhosis underwent elective endoscopic variceal ligation. Before the procedure, ascitic fluid was drawn under ultrasound guidance and sent for cell counts, Gram stain, and cultures. Two to 4 days afterward, a repeat ascitic fluid sample was sent for the same studies whether or not the patient had symptoms or signs suggestive of infection. Blood cultures were drawn both immediately before and after the endoscopic ligation procedure.

RESULTS

Of 67 subjects, 11 developed asymptomatic bacteremia with Gram-positive commensals. However, none of them progressed to peritonitis. Two patients who did not have bacteremia developed mild febrile peritonitis with Escherichia coli and were successfully treated with oral antibiotics. No other infectious complications were noted.

CONCLUSIONS

There is a significant risk of asymptomatic bacteremia and bacterial peritonitis after elective variceal ligation. The peritonitis does not seem to be related to the bacteremia, as patients who had bacteremia did not develop peritonitis and vice versa. In addition, the involved organisms were quite different. Unlike the bacteremia, postligation peritonitis may be a consequence of severe liver cirrhosis rather than the procedure itself. The clinical significance of postligation bacteremia is doubtful. With regard to peritonitis, in our opinion the use of prophylactic antibiotics should be reserved for patients with Child's C class cirrhosis, a recent history of variceal bleeding, a past history of bacterial peritonitis, or a comorbid immunosuppressive condition.

Farewell to bacteremia caused by endoscopic injection--effectiveness of a new injection catheter with a covered tip

BACKGROUND

Endoscopic injection has recently been reported as effective for several treatments. Because the common channel (suction and biopsy) is usually contaminated with aspirated gastrointestinal juice containing bacteria, often the tip of the injector needle is also. We report a new catheter needle with a covered tip designed to prevent bacteremia from endoscopic injection.

METHODS

The new covered needle catheter (Clisco needle) has a 23-gauge retractable needle with a 3 mm extrusion in one lumen. Its distal tip is covered with rubber, blocking infiltration of contaminated gut juice. Ten of these catheters and 10 other disposable needles were inserted through the colonoscope's biopsy channel for 10 patients. Needle tips were cut off after extrusion, and bacteria cultured were counted by standard plate count method.

RESULTS

All cultures from ordinary needles grew Escherichia coli, whereas only 3 new needles grew E. coli. Average counts of bacteria cultured from these 3 catheters and 10 disposable needles were 1-250 and 90-6.1 x 10(6), respectively. The difference was highly significant (p < 0.0001).

CONCLUSIONS

This new covered needle catheter reduces contaminating bacteria in patients who require endoscopic injection and may prevent bacteremia without antibiotic prophylaxis.

Manometry of esophageal varices: comparison of an endoscopic balloon technique with needle puncture

BACKGROUND

A noninvasive technique of pressure measurement in esophageal varices using an endoscopic balloon has been shown to be reliable in vitro. In the present study, this method was tested in vivo.

METHODS

Thirty-seven pressure measurements in esophageal varices were performed in 34 patients by two independent operators (A and B) using an endoscopic balloon and compared with measurements performed by needle puncture by a third operator (C).

RESULTS

Three measurements performed with the endoscopic balloon were rejected because they were noninterpretable. Measurements performed by A and B correlated well (correlation coefficient, 0.90); interobserver variability (r) was 0.88. Of 37 punctures performed for pressure measurements, 4 resulted in bleeding and 8 measurements were rejected as uninterpretable. Regression analysis showed a good correlation between the needle puncture and balloon techniques for pressure measurements performed by both operators (y = 5.3 + 1.0x, r = 0.8; y = 6.2 + 0.9x, r = 0.8), and analysis of variability showed a measurement bias of -5.3 +/- 4.1 and -4.1 +/- 3.5 cm H2O. No significant difference in variceal size measured with the endoscopic balloon or endoscopic forceps was found.

CONCLUSIONS

The endoscopic balloon allows measurement of pressure in esophageal varices without hazard to the patient; in addition, it may be used to assess the varix size.

Complications and limitations of injection sclerotherapy in portal hypertension

Injection sclerotherapy is now the accepted first line treatment for bleeding oesophageal varices, although it is associated with an impressive list of rare complications. The main problem concerns the strategy for uncontrollable or recurrent bleeding. Patients with uncontrolled bleeding may be referred for surgery after considerable blood loss and are then extremely difficult to assess. The effects of blood loss on liver function can lead to an unduly pessimistic assessment of liver status. An effective choice of emergency surgical procedure may require considerable surgical expertise. Oesophageal transection and devascularisation are satisfactory for many patients with oesophageal varices secondary to cirrhosis and should nearly always control bleeding. Difficulties arise in patients who are grossly obese and in those who have undergone extensive surgery in the upper abdomen. Problems may also be encountered in those treated by repeated sclerotherapy, which may have caused severe inflammatory change and thickening around the lower oesophagus and upper stomach. We believe that an emergency mesocaval shunt using either a vein graft or a synthetic material such as polytetrafluoroethylene is the procedure of choice for this difficult group of very sick patients. The surgical exposure is satisfactory and not unduly prolonged in even the largest patients and the technique does not interfere with any subsequent transplant operation. There is a greater choice in the management of the patient with less urgent bleeding from recurrent varices after sclerotherapy. Repeat sclerotherapy may be effective for small oesophageal varices while liver transplantation may be indicated in the patient with deteriorating liver function. A selective distal splenorenal shunt should be considered for patients with intact splenic and left renal veins and a mesocaval vein graft for the remainder. We would therefore suggest that surgery should still be considered for the management of portal hypertension, particularly in the following circumstances: (1) Uncontrollable bleeding during the initial course of sclerotherapy; (2) Life threatening haemorrhage from recurrent varices; (3) Bleeding from ectopic varices not accessible to sclerotherapy; (4) Uncontrollable bleeding from oesophageal ulceration secondary to injection sclerotherapy; (5) Severe, symptomatic hypersplenism; (6) For patients who live in communities remote from blood transfusion facilities and adequate medical care. The management of the complications of portal hypertension continues to pose problems. We believe that the best results should come from a combined management approach using injection sclerotherapy as primary treatment and surgery for complications and for haemorrhage from unusual anatomical sites.

A prospective controlled study of the risk of bacteremia in emergency sclerotherapy of esophageal varices

Reported incidences of bacteremia after endoscopy with esophageal variceal sclerotherapy are conflicting. A prospective controlled study was conducted to determine the frequency of bacteremia after emergency endoscopy with esophageal variceal sclerotherapy compared with frequency after elective esophageal variceal sclerotherapy and after emergency endoscopy in patients with upper gastrointestinal bleeding from nonvariceal sources. A total of 126 endoscopies were studied in 72 patients. Groups consisted of (a) emergency endoscopy without esophageal variceal sclerotherapy, 37 sessions with 36 patients; (b) elective esophageal variceal sclerotherapy, 33 sessions with 14 patients; and (c) emergency esophageal variceal sclerotherapy, 56 sessions with 36 patients. Blood cultures were obtained before and 5 and 30 minutes after endoscopy. There was a higher frequency of preendoscopic bacteremia in emergency esophageal variceal sclerotherapy (13%) than in emergency endoscopy alone (0%) (P = 0.02). Clinically significant bacteremia in emergency esophageal variceal sclerotherapy was observed in 7 of 56 (13%) sessions, compared with 0 of 33 in elective esophageal variceal sclerotherapy (P = 0.03) and 1 of 36 (3%) in emergency endoscopy alone (P = 0.45). Of these cases, 3 (5.4%) were potentially caused by emergency esophageal variceal sclerotherapy, but not clinically significant postendoscopic bacteremia was attributable to the procedure in the other groups.

The management of gastrointestinal haemorrhage by somatostatin after apparently successful endoscopic injection sclerotherapy for bleeding oesophageal varices

Twenty-two patients who experienced a severe haemorrhage from either oesophagitis (n = 8) or ulcers (n = 14) following injection sclerotherapy of their oesophageal varices were treated with intravenous administration of somatostatin (250 micrograms/h). Somatostatin was effective in controlling haemorrhage and preventing rebleeding in all eight patients bleeding from oesophagitis and in 12 of the 14 patients bleeding from oesophageal ulcers. In two patients with ulcers, haemorrhage persisted despite two periods of concominant balloon tamponade and somatostatin infusion and bleeding was eventually controlled by repeated hourly bolus injections of the hormone for 24 h superimposed on the continuous infusion. The results of this study suggest that somatostatin is an effective and safe treatment for the control of bleeding from either oesophagitis or ulcers following injection sclerotherapy of oesophageal varices.

Variceal injection sclerotherapy

With the development and widespread use of flexible endoscopes, injection sclerotherapy of oesophageal varices has advanced beyond the early stages. Although slightly different techniques and different sclerosants are used, the results are not strikingly different. The cumulative rate of adverse effects is in the range of 20 to 40%, with a procedure-related mortality of around 1 to 2%. Sclerotherapy is the best available treatment for haemostasis of acute oesophageal variceal bleeding. However, as a long-term therapy it is less effective in the prevention of recurrent gastrointestinal bleeding events, since obliteration of all varices often takes several months. Furthermore, extra-oesophageal bleeding is not amenable to sclerotherapy. Thus, if repeated injections fail to prevent recurrent bleeding, other options such as shunt surgery, transection, chronic medical portal decompression with beta-blockers or even liver transplantation should be considered according to the needs of the individual patient. Prophylaxis of first variceal haemorrhage was beneficial in selected patients with a high bleeding risk. It cannot, however, be generally recommended at present.

Bacteremia after injection of esophageal varices

Elective sclerotherapy for esophageal varices produces bacteremia in 4% to 53% of patients. The clinical importance of this phenomenon is uncertain. This study was undertaken to re-assess the incidence and clinical relevance of post-sclerotherapy bacteremia. Blood cultures were taken prior to and at 5 min and 4 h after endoscopy in 50 patients for whom sclerotherapy was planned. In the 41 patients in whom varices were injected, positive cultures were obtained 5 min after sclerotherapy in only 4 patients (10%) and all but 1 patient had other possible causes of bacteremia. After 4 h, all blood cultures were sterile. No infective complications were identified. Bacteremia appears to be an infrequent and transient event after elective sclerotherapy. Only patients with prosthetic heart valves or endocardial abnormalities require antibiotic prophylaxis.

A clinical controlled trial of endoscopic sclerotherapy for repeated esophageal variceal bleeding

Thirty-seven patients with postnecrotic cirrhosis of the liver and 13 patients with primary hepatoma were proven to have repeated bleeding from ruptured esophageal varices. Clinically controlled trials were performed by assigning patients to either sclerotherapy or control arms (25 patients each). Combined intra-variceal and para-variceal injection before an upper endoscopic examination was performed in the sclerotherapy group. In all 25 sclerotherapy cases (100%) hemostasis was successful, which was a statistically significant success rate compared to the control group (52.0%) (p less than 0.01). In the sclerotherapy group 20% (5/25 cases) developed rebleeding, which was less than the 48.0% (7 cases of continuous bleeding and 5 cases of rebleeding) of the control group (p less than 0.05). Four cases (16.0%) in the sclerotherapy group died of erosive gastritis with massive bleeding, compared to 8 fatalities (32.0%) in the control group, because of uncontrolled esophageal variceal bleeding. Endoscopic sclerotherapy is a very effective method for arresting bleeding esophageal varices, and for decreasing the rebleeding rate.

Bacteriaemia after injection sclerotherapy of oesophageal varices

Thirty consecutive alcoholic patients with biopsy-proven cirrhosis of the liver and oesophageal varices underwent a total of 47 upper intestinal endoscopies. During 31 of the endoscopies paravariceal sclerotherapy of oesophageal varices was performed. Blood cultures were drawn before and after the procedures. Bacteriaemia after endoscopy was detected on seven occasions: six after sclerotherapy and one after endoscopy without sclerotherapy. This difference did not reach statistical significance. The microorganisms cultured belonged to the normal flora of the skin or the oropharynx. Bacteriaemia was transient and had no clinical consequences.

Pressure measurement in oesophageal varices: preliminary report on a new non-invasive method

Pressure in oesophageal varices has been measured either by using an invasive puncture technique, or a non-invasive pneumatic pressure sensor. Experience with these techniques and their limitations prompted a new way of measuring pressure in oesophageal varices. This was done by observing through a transparent plastic balloon fixed to the tip of a gastroscope the pressure equilibrium between the varix and the balloon. One hundred measurements on an experimental model showed the reliability of the system. Measurements on eight patients with the balloon followed immediately by the puncture technique, showed good correlation.

Prophylaxis of first variceal hemorrhage in patients with liver cirrhosis

Prophylaxis of bleeding from esophageal varices is a very tempting concept at first glance, especially under the assumption of a high mortality associated with first variceal hemorrhage. Up to now four different measures have been tried for prophylaxis: portacaval shunt operation, devascularization procedures, sclerotherapy, and drugs. With the exception of portacaval shunts, ongoing controlled trials show a weak trend toward reduction of variceal bleeding and prolongation of survival in selected patients with compensated cirrhosis and large varices. However, prophylaxis of first variceal bleeding must still be regarded as experimental and should be restricted to controlled clinical studies.