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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.
Insights
Endoscopic variceal ligation can cause bacteremia and peritonitis in patients with esophageal varices. Prophylactic antibiotics may be beneficial for high-risk cirrhosis patients.
Area of Science:
- Gastroenterology
- Hepatology
- Infectious Diseases
Background:
- Endoscopic variceal ligation is increasingly preferred over sclerotherapy for esophageal varices.
- While ligation has a lower bacteremia risk than sclerotherapy, peritonitis incidence is less understood.
- This study prospectively evaluates risks of bacteremia and peritonitis post-ligation.
Purpose of the Study:
- To determine the incidence of bacteremia and bacterial peritonitis following elective endoscopic variceal ligation.
- To investigate the relationship between bacteremia and peritonitis after the procedure.
Main Methods:
- 67 patients with esophageal varices and ascites underwent elective endoscopic variceal ligation.
- Ascitic fluid and blood cultures were obtained before and after the procedure.
- Ascitic fluid was re-evaluated 2-4 days post-procedure, regardless of symptoms.
Main Results:
- 11 patients (16.4%) developed asymptomatic bacteremia, primarily with Gram-positive organisms.
- No patients with bacteremia developed peritonitis.
- Two patients without bacteremia developed mild, febrile Escherichia coli peritonitis, successfully treated with antibiotics.
Conclusions:
- Elective endoscopic variceal ligation carries a risk of asymptomatic bacteremia and bacterial peritonitis.
- Peritonitis appears unrelated to bacteremia, with different causative organisms.
- Post-ligation peritonitis may stem from severe cirrhosis; prophylactic antibiotics are suggested for high-risk patients (Child's C, recent bleeding, prior peritonitis, immunosuppression).