A study on Bacteraemia Following Upper Gastrointestinal Endoscopy and Sclerotherapy

To determine the risk of bacteraemia following upper Cl endoscopy, 93 patients were studied. Blood samples were collected for cultures just before, 5 minutes and one hour after the procedure. Cases were subjected lo diagnostic upper GI endoscopy or sclerotherapy. The rate of bacteraemia was 15.1% which was significantly higher in cases subjected 10 sclerolherapy (29%) than in diagnostic GI endoscopy (8.1%). Higher rates of bacteraemia in patients with decompensated than compensated liver disease but the differences were statistically insignificant. Persistence of bacteraemia for one hour following sclerotherapy was found in decompensated liver disease only (2.15%). No clinical evidence of infection was detected in postprocedure follow-up. The organisms isolated from bacteraemic cases were Strept. viridans (5 strains), Staph. epidermidis (3 strains), Diphtheroid species (3 strains), Staph. aureus (one strain), Strept. pyogenes (2 strains). These organisms were derived from the oropharynx. No obligatory anaerobic organisms were isolated. Introduction GASTROINTESTINAL (GI) endoscopy allowed great progress in the diagnostic accuracy and in the management of various GI diseases. GI endoscopy by necessity involves considerable manipulations and minor trauma to oropharyngeal and intestinal mucous 59 membrane [l]. Transient bacteraemia is known to occur with diagnostic and therapeutic procedures which involve manipulation of epithelial surfaces with endogenous bacterial flora (21. Studies on bacteraemia following upper GI endoscopy reported results vary from 0% to 10% [3]. Higher rates were report60 Hosny Rafla, et al ed following endoscopic sclerotherapy of oesophageal varices (OV). Nawar et al [4], reported 12%, while Botoman and Surawicz [5], reviewed some studies which reported rates of bacteraemia up to 31%. Such bacteraemia is of no consequence in healthy subjects yet they are of importance in cardiac cases and in those who are immune-suppressed [q. The aim of this work is to study bacteraemia following diagnostic upper GI endoscopy and sclerotherapy as regards its rate of development, its duration, the organisms involved and its relation to the state of liver affection and decompensation. Materials and Methods The subjects in this study were 93 patients attending Mataria Teaching Hospital. Their age ranged from 22 to 58 years old. They were of both sexes (72 males and 21 females). All patients were subjected to full clinical examination and laboratory investigations as regards liver function tests. None of them was febrile or received antibiotics for at least 15 days before the procedure. Cases were categorized into two groups according to the procedure done: Group-I: Cases subjected to diagnostic upper GI endoscopy (62 out of 93, 66.7% of total). These cases were subdivided on the basis of clinical and laboratory investigations into : Group la: Cases with no clinical or biochemical evidence of liver disease and the indication for endoscopy was to investigate dyspeptic symptoms or history of haematemesis (23 out of 62,37.1%). Group Ib: Cases showed palpable liver and spleen with no clinical or biochemical evidence of hepatic decompensation Child’s A classification (Child, Turcotte [A). The indication for endoscopy was to investigate dyspeptic symptoms and assessment of OV (16 out of 62,25.8%). Group Ic: Cases showed clinical and biochemical evidence of hepatic decompensation (Child’s B and C classification). They were investigated for dyspeptic symptoms and assessment of OV (23 out of 62,37.1%). Group II Cases with liver cirrhosis and portal hypertension (3lcases of 93,33.3% of total). They have history of haematemesis from ruptured OV. They were subjected to elective sclerotherapy. Ethanolamine oleate was the sclerosant used, the amount injected in each case was lo-14 cc. in 5-7 sites and injection was mostly intravariceal (1.5-2.5 cc in each site). Patients in this group were divided according to the state of hepatic compensation, on clis.ical and laboratory basis, into: Group IIu: Cases with compensated liver Bacteremia After Gl Endoscopy 61 cirrhosis, Child’s A classification. They were 9 out of 31 (29%). Group ZZb: Cases with decompensated liver (Child’s B and C classification), 22 cases out of 31 (71%). The instrument used was Olympus GIF XQ20. Sterilization of the endoscope and other equipment was done according to the manufacturers instruction. Meticulous physical cleaning of the instrument, then immersion in 2% aqueous alkaline glutaraldehyde for 10 minutes [S]. Bacteriological Study Three blood samples were taken from each case for blood culture. The blood samples were taken just before the procedure, 5 minutes and one hour after the procedure. Duplicate blood cultures from each sample were done, incubated aerobically and anaerobically at 37°C. Subcultures were done every other day for 15 days. The isolated organisms were identified by standard techniques as regards the morphology, cultural characters and biochemical reaction tests [9]. Patients were observed for two weeks afier the procedure for the development of fever or evidence of infection. Results All patients were not bacteraemic before the procedure. Bacteraemia was detected in 14 cases out of 93 patients (15.1%) after the procedure. Peak bacteraemia was 5 minutes afier endoscopy which was transient in 12 out of 14 cases (85.7%). Only 2 cases (2.15%) were positive blood culture in one hour samples after the procedure. The difference was highly significant (Table 1). Clinical follow-up of these cases showed no evidence of infection or fever. Comparing the rate of bacteraemia after diagnostic upper GI endoscopy (group I) and sclerotherapy (group II) 5 minutes afTable (1): Rate of Bacteraemia After Endoscopic Procedures. Total No. Positive blood cultures of cases Before the procedure After the procedure