Liver, Pancreas and Biliary Tract| Volume 50, ISSUE 4, P366-369, April 2018

Elective endoscopic variceal ligation is not a risk factor for bacterial infection in patients with liver cirrhosis

Published:December 20, 2017DOI:



      Patients with cirrhosis are at high risk of bacterial infections. Invasive procedures are generally believed to increase this susceptibility.


      We investigated the incidence of bacterial infections in cirrhotic patients undergoing elective endoscopic variceal ligation (EVL).


      We enrolled 60 consecutive cirrhotic patients who underwent a total number of 112 elective EVL procedures. One to seven bands were applied at each session until variceal eradication. Markers of inflammation/infection and blood cultures were obtained before and 24 h after EVL.


      Aetiology of liver disease was metabolic in 27 (45%), viral in 21 (35%), alcoholic in 12 (20%) patients. Child–Pugh class A/B/C distribution was 29/26/5, respectively, 23 (38%) patients had ascites and 15 (25%) had hepatocellular carcinoma. Blood cultures were negative in all samples before EVL, whereas 3/112 (2.7%) cultures tested positive after endoscopy. Streptococcus mitis and Staphylococcus epidermidis were isolated in 1 and 2 cases, respectively. None of these three patients developed any features of clinically relevant infection, suggesting that the positive cultures were an expression of a transient bacteraemia with no clinical sequelae.


      Bacterial infection is an uncommon occurrence after elective EVL in cirrhotic patients, and antibiotic prophylaxis is not necessary in this clinical setting.


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        • Borzio M.
        • Salerno F.
        • Piantoni L.
        • Cazzaniga M.
        • Angeli P.
        • Bissoli F.
        • et al.
        Bacterial infection in patients with advanced cirrhosis: a multicentre prospective study.
        Dig Liver Dis. 2001; 33: 41-48
        • Cheruvattath R.
        • Balan V.
        Infections in patients with end-stage liver disease.
        J Clin Gastroenterol. 2007; 41: 403-411
        • ASGE Standards of Practice Committee
        • Banerjee S.
        • Shen B.
        • Baron T.H.
        • Nelson D.B.
        • Anderson M.A.
        • et al.
        Antibiotic prophylaxis for GI endoscopy.
        Gastrointest Endosc. 2008; 67: 791-798
        • Tandon P.
        • Garcia-Tsao G.
        Bacterial infections, sepsis, and multiorgan failure in cirrhosis.
        Semin Liver Dis. 2008; 28: 26-42
        • Bonnel A.R.
        • Bunchorntavakul C.
        • Reddy K.R.
        Immune dysfunction and infections in patients with cirrhosis.
        Clin Gastroenterol Hepatol. 2011; 9: 727-738
        • de Franchis R.
        • Baveno V.I.F.
        Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension.
        J Hepatol. 2015; 63: 743-752
        • Tseng C.C.
        • Green R.M.
        • Burke S.K.
        • Connors P.J.
        • Carr-Locke D.L.
        Bacteremia after endoscopic band ligation of esophageal varices.
        Gastrointest Endosc. 1992; 38: 336-337
        • Berner J.S.
        • Gaing A.A.
        • Sharma R.
        • Almenoff P.L.
        • Muhlfelder T.
        • Korsten M.A.
        Sequelae after esophageal variceal ligation and sclerotherapy: a prospective randomized study.
        Am J Gastroenterol. 1994; 89: 852-858
        • Kulkarni S.G.
        • Parikh S.S.
        • Dhawan P.S.
        • Chachad H.
        • Jambavalikar M.B.
        • Koppikar G.V.
        • et al.
        High frequency of bacteremia with endoscopic treatment of esophageal varices in advanced cirrhosis.
        Indian J Gastroenterol. 1999; 18: 143-145
        • Lin O.S.
        • Wu S.S.
        • Chen Y.Y.
        • Soon M.S.
        Bacterial peritonitis after elective endoscopic variceal ligation: a prospective study.
        Am J Gastroenterol. 2000; 95: 214-217
        • Maulaz E.B.
        • de Mattos A.A.
        • Pereira-Lima J.
        • Dietz J.
        Bacteremia in cirrhotic patients submitted to endoscopic band ligation of esophageal varices.
        Arq Gastroenterol. 2003; 40: 166-172
        • Bonilha D.Q.
        • Correia L.M.
        • Monaghan M.
        • Lenz L.
        • Santos M.
        • Libera E.D.
        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
        • Zuckerman M.J.
        • Jia Y.
        • Hernandez J.A.
        • Kolli V.R.
        • Norte A.
        • Amin H.
        • et al.
        A prospective randomized study on the risk of bacteremia in banding versus sclerotherapy of esophageal varices.
        Front Med (Lausanne). 2016; 3: 16
        • Garcia-Tsao G.
        • Abraldes J.G.
        • Berzigotti A.
        • Bosch J.
        Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases.
        Hepatology. 2017; 65: 310-335
        • de Franchis R.
        • Baveno V.F.
        Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension.
        J Hepatol. 2010; 53: 762-768
        • Dionigi E.
        • Garcovich M.
        • Borzio M.
        • Leandro G.
        • Majumdar A.
        • Tsami A.
        • et al.
        Bacterial infections change natural history of cirrhosis irrespective of liver disease severity.
        Am J Gastroenterol. 2017;
        • Klimova K.
        • Padilla C.
        • Avila J.C.
        • Clemente G.
        • Ochoa A.
        Epidemiology of bacterial infections in patients with liver cirrhosis. Experience in a Spanish tertiary health center.
        Biomedica. 2016; 36: 121-132
        • Coelho J.C.
        • Claus C.M.
        • Campos A.C.
        • Costa M.A.
        • Blum C.
        Umbilical hernia in patients with liver cirrhosis: a surgical challenge.
        World J Gastrointest Surg. 2016; 8: 476-482
        • Seol Y.J.
        • Yoon T.R.
        • Lee D.H.
        • Lee S.H.
        • Park K.S.
        Outcome analysis of hip or knee arthroplasty in patients with cirrhotic liver disease.
        J Orthop. 2017; 14: 171-175
        • Fernandez J.
        • Navasa M.
        • Gomez J.
        • Colmenero J.
        • Vila J.
        • Arroyo V.
        • et al.
        Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis.
        Hepatology. 2002; 35: 140-148
        • Ebisutani C.
        • Sato S.
        • Nishi K.
        • Inoue H.
        • Yoshie T.
        • Kinoshita Y.
        Antibiotic prophylaxis in transcatheter treatment of hepatocellular carcinoma: an open randomized prospective study of oral versus intravenous administration.
        Intern Med. 2010; 49: 1059-1065
        • Rossle M.
        TIPS: 25 years later.
        J Hepatol. 2013; 59: 1081-1093
        • Bernard B.
        • Grange J.D.
        • Khac E.N.
        • Amiot X.
        • Opolon P.
        • Poynard T.
        Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis.
        Hepatology. 1999; 29: 1655-1661
        • Jia Y.
        • Dwivedi A.
        • Elhanafi S.
        • Ortiz A.
        • Othman M.
        • Zuckerman M.
        Low risk of bacteremia after endoscopic variceal therapy for esophageal varices: a systematic review and meta-analysis.
        Endosc Int Open. 2015; 3: E409-E417
        • Jager E.
        • Hausemann A.
        • Hofmann H.
        • Otto U.
        • Heudorf U.
        [Hygiene in endoscopy in clinic and practice 2013 in comparison with 2003–structure and process quality].
        Z Gastroenterol. 2014; 52: 1402-1407
        • Authors/Task Force M
        • Ryden L.
        • Grant P.J.
        • Anker S.D.
        • Berne C.
        • Cosentino F.
        • et al.
        ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: the Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD).
        Eur Heart J. 2013; 34: 3035-3087