Septicaemia After Colonoscopy in Patients With

450 Gut, 1991,32,450-451 Septicaemia after colonoscopy in patients with

cirrhosis Gut: first published as 10.1136/gut.32.4.450 on 1 April 1991. Downloaded from

j R Thornton, M S Losowsky

Abstract PATIENT 2 Two patients with ulcerative colitis and In 1987, a 34 year old man underwent routine chronic active hepatitis with cirrhosis, who colonoscopy because ofhis ulcerative colitis of 12 developed Gram negative septicaemia after years' duration. Twenty three years earlier a colonoscopy are described. These and two liver biopsy had shown that he had chronic similar reported cases indicate that giving active hepatitis and cirrhosis. Hepatitis B prophylactic antibiotics to patients with cir- markers were negative. In 1983 he developed rhosis undergoing colonoscopy should be con- ascites and had remained on spironolactone since sidered, particularly when the cirrhosis is then. advanced. At the time ofhis colonoscopy he claimed that he felt reasonably well and was continuing to work. However, he had a moderate amount of Prophylactic antibiotics have been advised for ascites. His medication was: prednisolone 5 mg patients undergoing colonoscopy who have daily, spironolactone 200 mg daily, and sul- valvular heart disease, cardiac prostheses, severe phasalazine 1 g twice daily. Preoperative blood immunodepression, or hepatic cirrhosis with tests were: bilirubin 53 ,umol/1, alanine amino- ascites.' The last of these recommendations is transferase 38 IU/, alkaline phosphatase 206 IU/ based on a single case report in which it was not 1, albumin 28 g/l, prothrombin time 16 seconds certain that colonoscopy was responsible for the (control 14 seconds). infection, as hepatic angiography was performed After bowel preparation with three litres of the day before peritonitis developed.' We were Golytely, colonoscopy to the caecum was per- unaware of this case but our recent experience formed. An inactive, total colitis was found. Six suggests that this recommendation is valid. biopsy specimens were taken. His spironolactone dosage was doubled to 400 mg daily. http://gut.bmj.com/ Three days later, he was readmitted to hospital Case reports complaining that for the last two days he had felt unwell, had been vomiting, and had diffuse PATIENT I abdominal pain. On examination he had A 56 year old woman underwent routine colonos- generalised abdominal tenderness. A diagnostic copy. She had had ulcerative colitis involving the ascitic tap showed a very high white cell count of on September 29, 2021 by guest. Protected copyright. whole of her colon for 25 years. For the past 1 7/1 (88% neutrophils). The ascitic fluid and seven years, the colitis had been quiescent. Ten two blood cultures subsequently grew E coli. years earlier, she had become jaundiced and a Urine culture was sterile. An abdominal ultra- liver biopsy specimen showed chronic active sound showed a small liver, enlarged spleen, and hepatitis and cirrhosis. She was negative for moderate ascites. The biliary tree was not dilated hepatitis B markers. Nine and five months and no gall stones were seen. He recovered after before her admission for colonoscopy, she had treatment with cefuroxime and gentamicin. been admitted for treatment ofascites. Fifteen months later, he was admitted for At this admission, she felt reasonably well. assessment for a liver transplant as he had Her medication was prednisolone 7 5 mg daily become increasingly tired, more jaundiced and spironolactone 100 mg daily. Ascites was not (serum bilirubin 116 [tmol/l), and his ascites had evident on clinical examination. Pre-endoscopy become resistant to diuretic treatment. Because blood tests showed: bilirubin 88 ,tmol/1 (normal of the considerable immunosuppressive treat- less than 15 ,tmol/l), alanine aminotransferase 41 ment he would receive after a transplant, which IU/1 (normal less than 35 IU/1), alkaline phospha- might promote the development of any pre- tase 224 IU/1 (normal less than 241 IU/1), existing colonic dysplasia or neoplasia, it was albumin 25 g/l (normal greater than 37 g/l), decided to perform a further colonoscopy. This prothrombin time 20 seconds (control 14 time the patient was given antibiotic prophylaxis seconds). with ciprofloxacin 200 mg and metronidazole After bowel preparation with three litres of 500 mg intravenously one hour before and eight Golytely, colonoscopy to the caecum was per- hours afterwards. No clinical evidence of infec- Department of Medicine, St James's University formed. She had inactive, total colitis. Four tion subsequently developed. Two days after the Hospital, Leeds biopsy specimens were taken. The next day she endoscopy, blood and ascitic cultures were J R Thornton developed a fever of 39 5°C. Two blood cultures sterile, and the ascitic white cell count was M S Losowsky grew Eschenchia coli. Urine cultures were nega- OdI/RI. Correspondence to: Dr J R Thornton, Department tive. Abdominal ultrasound showed a small liver of Medicine, St James's without dilated bile ducts. There were no stones University Hospital, Leeds LS9 7TF. in the biliary system. Ascites was absent. She was Discussion Accepted for publication treated with cephradine and made a good These two patients indicate that potentially fatal 4 June 1990 recovery. infections may occur if prophylactic antibiotics Septicaemnia after colonoscopy inpatients with cirrhosis 451

are not used in patients with cirrhosis under- uncommon consideration. On the basis of our going colonoscopy. Our first patient shows that experience and the two other similar cases this may happen even if ascites is absent, though reported,'7 it seems advisable at least to give

this patient had had ascites previously. The antibiotics to those patients with cirrhosis who Gut: first published as 10.1136/gut.32.4.450 on 1 April 1991. Downloaded from second patient shows that antibiotics may be have or have had ascites, or those who are effective in preventing serious infection after approaching or have received liver trans- colonoscopy, despite the presence of ascites and plantation. previous ascitic infection. Bacteraemia may occasionally follow colonoscopy, the reported incidence ranges from 1 Macrae FA, Tan KG, Williams CB. Towards safer colonoscopy: 017%.2 Patients with liver disease are likely to a report on thecomplications of5000 diagnostic or therapeutic colonoscopies. Gut 1983; 24: 376-83. be less able to clear this bacteraemia because of 2 Meyer GW. Prophylaxis of infective endocarditis during their compromised immune function and portal colonoscopy: report of a survey. Gastrointest Endosc 1981; 27: 58-9. systemic shunting of blood away from hepatic 3 Runyon BA. Spontaneous bacterial peritonitis: an explosion of Kupffer cells.3 In addition, our patients were information. Hepatology 1988; 8: 171-5. 4 Olsson R, Hulthen L. Concurrence of ulcerative colitis and taking small doses of predisolone, which may chronic active hepatitis. Scand J Gastroenterol 1975; 10: have further impaired their immune systems. 331-4. 5 Dew MJ, Thompson H, Allan RN. The spectrum of hepatic Whether it would be prudent to give anti- dysfunction in inflammatory bowel disease. Q J Med 1979; biotics to all patients with cirrhosis before 48:113-35. 6 Chapman RWG, Arborgh BAM, Rhodes JM et al. Primary colonoscopy is unclear. As ulcerative colitis is sclerosing cholangitis: a review of its clinical features, associated with an increased incidence of serious cholangiography and hepatic histology. Gut 1980; 21: 870-7. 7 Shrake PD, Troiano F, Rex DK. Peritonitis following colonos- liver diseases such as sclerosing cholangitis and copy in a cirrhotic with ascites. AmJ7 Gastroenterol 1989; 84: chronic active hepatitis," this will not be an 453-4. http://gut.bmj.com/ on September 29, 2021 by guest. Protected copyright.