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.
3 Zuckerman MJ, Menzies IS, Ho H et al. Assessment of intestinal permeability and absorption in cirrhotic patients with ascites using combined sugar probes. Dig Dis Sci 2004; 49: 621-626
4 Lin OS, Wu SS, Chen YY et al. Bacterial peritonitis after elective endoscopic variceal ligation: a prospective study. Am J Gastroenterol 2000; 95: 214-217
7 Lo GH, Lai KH, Shen MT et al. A comparison of the incidence of transient bacteremia and infectious sequelae after sclerotherapy and rubber band ligation of bleeding esophageal varices. Gastrointest Endosc 1994; 40: 675-679
10 Camara DS, Gruber M, Barde CJ et al. Transient bacteremia following endoscopic injection sclerotherapy of esophageal varices. Arch Intern Med 1983; 143: 1350-1352
11 Ho H, Zuckerman MJ, Wassem C. A prospective controlled study of the risk of bacteremia in emergency sclerotherapy of esophageal varices. Gastroenterology 1991; 101: 1642-1648
12 Qureshi W, Adler DG, Davila R et al. ASGE Guideline: the role of endoscopy in the management of variceal hemorrhage, updated July 2005. Gastrointest Endosc 2005; 62: 651-655
13 Garcia-Tsao G, Sanyal AJ, Grace ND et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol 2007; 102: 2086-2102
15 Moher D, Liberati A, Tetzlaff J et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009; 151: 264-269
16 Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010; 25: 603-605
17 Berner JS, Gaing AA, Sharma R et al. Sequelae after esophageal variceal ligation and sclerotherapy: a prospective randomized study. Am J Gastroenterol 1994; 89: 852-858
18 Kulkarni SG, Parikh SS, Dhawan PS et al. High frequency of bacteremia with endoscopic treatment of esophageal varices in advanced cirrhosis. Indian J Gastroenterol 1999; 18: 143-145
19 Bonilha DQ, Correia LM, Monaghan M et al. Prospective study of bacteremia rate after elective band ligation and sclerotherapy with cyanoacrylate for esophageal varices in patients with advanced liver disease. Arq Gastroenterol 2011; 48: 248-251
21 Brayko CM, Kozarek RA, Sanowski RA et al. Bacteremia during esophageal variceal sclerotherapy: its cause and prevention. Gastrointest Endosc 1985; 31: 10-12
22 Snady H, Korsten MA, Waye JD. The relationship of bacteremia to the length of injection needle in endoscopic variceal sclerotherapy. Gastrointest Endosc 1985; 31: 243-246
26 Rolando N, Gimson A, Philpott-Howard J et al. Infectious sequelae after endoscopic sclerotherapy of oesophageal varices: role of antibiotic prophylaxis. J Hepatol 1993; 18: 290-294
27 Selby WS, Norton ID, Pokorny CS et al. Bacteremia and bacterascites after endoscopic sclerotherapy for bleeding esophageal varices and prevention by intravenous cefotaxime: a randomized trial. Gastrointest Endosc 1994; 40: 680-684
28 da Silveira RohrMR, Siqueira ES, Brant CQ et al. Prospective study of bacteremia rate after elastic band ligation and sclerotherapy of esophageal varices in patients with hepatosplenic schistosomiasis. Gastrointest Endosc 1997; 46: 321-323
29 Maulaz EB, de Mattos AA, Pereira-Lima J et al. Bacteremia in cirrhotic patients submitted to endoscopic band ligation of esophageal varices. Arq Gastroenterol 2003; 40: 166-172
30 Rey JR, Axon A, Budzynska A et al. Guidelines of the European Society of Gastrointestinal Endoscopy (E.S.G.E.) antibiotic prophylaxis for gastrointestinal endoscopy. European Society of Gastrointestinal Endoscopy. Endoscopy 1998; 30: 318-324
31 Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med 1995; 123: 280-287
33 Stiegmann GV, Goff JS, Michaletz-Onody PA et al. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices. NEJM 1992; 326: 1527-1532
34 Laine L, el-Newihi HM, Migikovsky B et al. Endoscopic ligation compared with sclerotherapy for the treatment of bleeding esophageal varices. Ann Intern Med 1993; 119: 1-7
35 Baroncini D, Milandri GL, Borioni D et al. A prospective randomized trial of sclerotherapy versus ligation in the elective treatment of bleeding esophageal varices. Endoscopy 1997; 29: 235-240
37 Wahl P, Lammer F, Conen D et al. Septic complications after injection of N-butyl-2-cyanoacrylate: report of two cases and review. Gastrointest Endosc 2004; 59: 911-916
39 Chang YJ, Park JJ, Joo MK et al. Long-term outcomes of prophylactic endoscopic histoacryl injection for gastric varices with a high risk of bleeding. Dig Dis Sci 2010; 55: 2391-2397
42 Lee S, Son SC, Han MJ et al. Increased intestinal macromolecular permeability and urine nitrite excretion associated with liver cirrhosis with ascites. World J Gastroenterol 2008; 14: 3884-3890
43 Fukui H. How leaky gut and endotoxemia induce bacterial infection in cirrhosis and gastrointestinal hemorrhage?. J Gastroenterol Hepatol 2011; 26: 423-425
