Letters Indian Journal of Gastroenterology 2005 Vol 24 May - June

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                                                                  1. Landau GD, Saunders WH. The effect of chlorine bleach on
                                                                     the esophagus. Arch Otolaryngol 1964;80:174-6.
                                                                  2. Pike DG, Peabody JW Jr, Davis EW, Lyons WS. A re-
                                                                     evaluation of the dangers of Clorox ingestion. J Pediatr
                                                                  3. Kirsh MM, Ritter F. Caustic ingestion and subsequent
                                                                     damage to the oropharyngeal and digestive passages. Ann
                                                                     Thorac Surg 1976;21:74-82.
Fig: Diffuse exudation and hyperemia in upper part of esophagus

years ago.
      Upper GI endoscopy revealed diffuse inflammatory                 A report of post-ERCP Pseudomonas
exudation and hyperemia in the upper esophagus (Fig).                     aeruginosa infection outbreak
Passage of the endoscope through the esophagus was
difficult. Barium swallow showed concentric narrowing             Cholangitis and bacteremia following ERCP can occur
of the distal esophagus. An attempt at balloon dilatation         due to exogenous source (contaminated endoscope
was unsuccessful as the stricture was long and the pa-            or accessories) or endogenous bacterial flora.
tient could not tolerate the procedure. Thus, total esoph-        Pseudomonas aeruginosa is implicated in post-ERCP
ageal replacement with colonic interposition was done.            sepsis transmitted through endoscopes or ERCP
Examination of the specimen revealed severe inflamma-             accessories. 1 Guidelines for disinfection of scopes 2,3
tion, erosion and ulceration.
                                                                  and reprocessing of accessories 4,5,6 have been
      Detailed history revealed that the patient habitually       proposed to prevent transmission of infection through
left his dentures in a glassful of detergent at night in
                                                                  endoscopes. We report an outbreak of Pseudomonas
order to prevent discoloration. As there was no other
likely cause, we attributed the esophageal stricture to re-       sepsis after ERCP and discuss the possible lapses in
curring exposure to detergents. Among the ingredients             the disinfection process.
in the detergent used by him (Ariel; Procter and Gamble,                Three cases of post-ERCP sepsis were noted within
Turkey) the possible cause of the stricture was the bleach-       a week in our endoscopy unit.
ing agent, sodium carbonate. There are no reports about                 Case 1: A 35-year-old man with obstructive jaun-
corrosive mucosal injuries due to the other constituents          dice due to common bile duct (CBD) stone was referred
(unspecified surfactant[s], sodium carbonate 15%-40%,             after failed canulation at ERCP elsewhere. We found a
proteolytic enzyme [subtilisin], alkyl [C10-C16]                  large CBD stone that could not be extracted; biliary drainage
benzenesulfonic acid, sodium salt 7%-13%).                        was established with a 10 F stent and nasobiliary drain.
     Household bleach ingestion is the most com-                  Empirical antibiotics (cefoperazone plus sulbactam and
mon toxic exposure in the United States. These                    amoxicillin plus clavulinic acid) were started; these were
bleaches have relatively low toxicity, and may be                 changed when blood and bile culture reports (both grew
                                                                  Pseudomonas aeruginosa) were available (Table). Despite
regarded as only an esophageal irritant. In animal
                                                                  adequate biliary drainage (reduction of bilirubin and
studies, prolonged contact times are necessary to                 pneumobilia) and appropriate antibiotics he continued to
induce injury detectable by endoscope, and exten-                 have uncontrolled sepsis and died of multi-organ failure.
sive necrosis or stricture formation did not occur. 1                   Case 2: A 42-year-old woman underwent ERCP clear-
In a case series of 129 patients who had ingested                 ance for post-cholecystectomy retained CBD stone. She
bleach, only two had evidence of mild esophageal                  developed fever on the second post-procedure day. The
injury on endoscopy and no complications or conse-                initial antibiotic was changed empirically (ciprofloxacin
quence were found. 2                                              to cefoperazone plus sulbactam and amikacin); a naso-
                                                                  biliary drain was placed on the third day because of per-
     In conclusion we believe that this patient devel-            sisting fever and leukocytosis. Bile culture grew Pseudomo-
oped esophageal stricture as a result of chronic ex-              nas aeruginosa which was sensitive to the previous anti-
posure to a detergent that contains calcium carbon-               biotics (Table). She became afebrile after 5 days.
ate as bleaching agent. It is known that mucosal                        Case 3: A 58-year-old man with jaundice and pruri-
damage is also influenced by duration of exposure                 tus (Bismuth type 1 benign biliary stricture and underly-
to a corrosive agent. 3                                           ing chronic pancreatitis) underwent ERCP (dilatation and
               M R Mas, M I Yilmaz,* A Sonmez,                    plastic stent placement). He developed high fever and
                                                                  leukocytosis on the second day, for which empirical anti-
               T Dogru, B Comert,** L Yamanel**
                                                                  biotics (cefoperazone plus sulbactam and amikacin) were
    Departments of Internal Medicine, *Nephrology                 started. Blood culture grew Pseudomonas aeruginosa,
    and **Emergency Medicine, Gulhane School of                   which was sensitive to the prescribed antibiotic (Table).
                   Medicine, 06018 Ankara, Turkey                 He became afebrile.

                                                       Indian Journal of Gastroenterology 2005 Vol 24 May - June 131

Table: Culture and sensitivity pattern of bile and blood        of infection. The first patient had undergone a pre-
 Case Sample                 Organism and sensitivity           vious procedure and he may have been infected be-
 1 Blood and bile Both grew Pseudomonas aeruginosa
                       S- mero. R- ampi, cipro, genta, amika,        Guidelines for endoscope disinfection 2,3 stress
                       cefotax, ceftr, cefo-sulb                on mechanical cleaning of scope. Adequate dipping
                       Sensitivity same for both isolates       of endoscopes in glutaraldehyde between procedures
 2 Blood and bile Blood sterile, bile Pseudomonas               and regular checking of activation time of glutaral-
                       aeruginosa                               dehyde are important. Pseudomonas aeruginosa thrives
                       S- mero, amika. R- ampi, cipro, genta,   on moisture, and alcohol drying at the end of the
                       cefotax, ceftr, cefo-sulb                day is recommended. 2,3 In this outbreak, two pa-
 3 Blood               Pseudomonas aeruginosa
                                                                tients (cases 2 and 3) had consecutive procedures
                       S- mero, amika, cefo-sulb. R- ampi,
                       cipro, genta, cefotax
                                                                and there may have been a lapse in mechanical cleaning
 S= sensitive, R= resistant                                     and glutaraldehyde exposure in between.
Mero- meropenem, ampi- ampicillin, genta- gentamicin,                Reprocessing of ERCP accessories is a vital
amika- amikacin, cipro- ciprofloxacin, cefotax - cefotaxime,    issue in developing countries. 4,5,6 Complexity of ac-
ceftr- ceftrioxone, cefo-sulb - cefoperazone plus sulbactam     cessories, such as grooves in wires and fine chan-
                                                                nels of canulas, make mechanical cleaning difficult.
      Case 1 was done as the last case in a list of 6 cases;
                                                                Mechanical cleaning and 10-minute exposure in glu-
no other patient on that day developed septic complica-         taraldehyde, as recommended for endoscopes, have
tion. Cases 2 and 3 were done on the same day as the 4th        to be followed for accessories as well. Use of en-
and 5th cases of a total of 5; no other patient on that day     zymatic solutions, ultrasonic cleaners, and treating
developed sepsis.                                               heat-sensitive accessories such as canula with eth-
      We follow the APCDE guidelines for disinfection of        ylene oxide have been suggested.
endoscopes 2 and use reprocessed accessories. The clean-             Piyush Ranjan, Kanak Das, Archana Ayyagiri,*
ing and disinfection is done by trained endoscopy staff.
                                                                         Vivek Anand Saraswat, Gourdas Choudhuri
Tap water is used for mechanical cleaning and glutaralde-
hyde as disinfectant. On supervising the mechanical clean-                     Departments of Gastroenterology and
ing, we found it to be inadequate (remains of blood and           *Microbiology, Sanjay Gandhi Postgraduate Insti-
bile stain found on guidewires and sphincterotome) and                 tute of Medical Sciences, Lucknow 226 014
the water bottle of the processor was not cleaned for 4
weeks. The activation time of glutaraldehyde was found                                  References
to be within the recommended time. However, it could not
                                                                1.   Moayyedi P, Lynch D, Axon A. Pseudomonas and endo-
be ascertained whether appropriate glutaraldehyde expo-
                                                                     scopy. Endoscopy 1994;26:554-8.
sure was maintained between the procedures.
                                                                2.   Tandon RK. Disinfection of gastrointestinal endoscopes
      Cultures were taken from the accessory channel of              and accessories. J Gastroenterol Hepatol 2000;15(S):G69-
the duodenoscope, water bottle and commonly used ac-                 72.
cessories such as sphicterotome, biliary guidewires, dormia     3.   Walter VA, DiMarino AJ Jr. American Society of Gas-
basket and biliary balloon. Pseudomonas aeruginosa was               trointestinal Endoscopy – Society of Gastroenterology Nurses
isolated from all samples; the ERCP canula and water bottle          and Associates endoscope reprocessing guidelines. Gastrointest
also grew Enterobacter fecium and Proteus mirabilis.                 Endosc Clin N Am 2000;10:265-73.
      As a remedial measure we instituted supervised me-        4.   Haber G. Reprocessing of accessories in endoscopic retro-
chanical cleaning and drying of the scopes. Accessories              grade cholangiopancreatography. J Gastroenterol Hepatol
were subjected to ethylene oxide sterilization. Repeat cul-          2000;12:86-9.
tures after one month from all previous sites were sterile.     5.   Tandon RK, Ahuja V. Non United States guidelines for
                                                                     endoscopic reprocessing. Gastrointest Endosc Clin N Am
     We report an outbreak of post-ERCP Pseudomonas
aeruginosa sepsis involving 3 patients. Although we             6.   Ramakrishna BS. Safety of technology: infection control
have not done serotyping or molecular typing, iso-                   standards in endoscopy. J Gastroenterol Hepatol 2002;17:
lation of similar organisms from the patient and                     361-8.
endoscopes and accessories provides circumstantial              Correspondence to: Dr Choudhuri, Professor and Head.
evidence to implicate the latter as the potential source        Fax: (522) 266 8017. E-mail:

132 Indian Journal of Gastroenterology 2005 Vol 24 May - June

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