Endoscopy 9 (1977) 231-234 0 Georg Thieme Verlag, Stuttgart
How often does Bacteraemia Occur following Endoscopic Retrograde Cholangiopancreatography S. K. Lam, J. K. C. Tsui Dept. of Med., Univ. of Hong Kong, Queen Mary Hospital, Hong Kong P. K. W. Chan Dept. of Surgery, Univ.of Hong Kong, Queen Mary Hospital, Hong Kong K. P. Wong Institute of Radiology, Queen Mary Hospital, Hong Kong G. B. Ong Dept. of Surgery, Univ. of Hong Kong, Queen Mary Hospital, Hong Kong
Summary
In order to determine the risk of bacteraemia from ERCP, we cultured blood specimens from 83 patients before, during and 15 mm, 1, 6, 12 and 24 hours after the examination as well as in the subsequent week whenever fever occurred.
Wie häufig kommt es nach einer endoskopisch retrograden Cholangiopankreatographie (ERCP) zu einer Bakteriämie? Um Aufschluf3 iiber das Risiko einer Bakteriämie
failed. Of the 20 patients with normal biliary
nach ERCP zu erhalten, wurden bei 83 Patienten vor, während, 1, 6, 12 und 24 Std. nach der Untersuchung sowie bei einer später auftretenden Fieberattacke Blutkulturen angelegt. Bei 20 Patienten, bei denen nur eine Duodenoskopie, aber
and/or pancreatic ducts positive culture was obtained in one patient in whom inadvertent multiple injections of contrast material into the pan-
keine ERCP durchgefiihrt worden war, wurde keine Bakteriämie gefunden. Von 20 Patienten mit normalem Pankreas- und/oder Gallengang
creatic duct had resulted in the occurrence of a pyelogram. Four positive cultures were found
wurden in einem Fall positive Kulturen gesehen. Bei diesem Patienten hatten multiple Kontrast-
amongst the 43 patients in whom an obstructive
mittelinstillationen in den Pankreasgang zum
pathology in the biliary or pancreatic system was present. These data support the need of on heart defects.
Auftreten eines Pyelogramms gefiihrt. 4 positive Kulturen kamen bei 43 Patienten mit obstruktiven Gangveränderungen zur Beobachtung. Die Befunde unterstreicben die Notwendigkeit einer
Key-Words: ERCP, bacteriaemia after ERCP,
antibiotisch'en Therapie.
No bacteraemia was found in the 20 patients who had duodenoscopy only, i.e. in whom ERCP
antibiotic prophylaxis for patients with valvular
duodenoscopy, antibiotic prophylaxis.
Introduction
Transient bacteraemia has been reported after sigmoidoscopy (3, 9, 14), upper gastrointestinal endoscopy (13) and colonoscopy (5), although the occurrence after the latter procedure is still controversial (8, 10, 12). This has important implications in patients
with congenital or acquired valvular heart defects and calls for the need of antibiotic prophylaxis in these individuals when they undergo such procedures.
While cholangitic and pancreatic sepsis represent real hazards in endoscopic retro16 Endoscopy 4/77
grade cbolangiopancreatography (ERCP) (2, 4, 15), information concerning the incidence
of bacteraemia related to this procedure is not available. Methods Patients: In a consecutive series of 87 patients subjected to routine ERCP, blood cultures were carried out in 83 patients. The other four were not studied as they were on antibiotic treatment when the examination was performed. There were 48 males, age ranging from 25 to 78 (mean: 48.9
years) and 35 females, age ranging from 12 to 96 (mean: 62.1 years).
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
(ERCP)?
S. K. Lam, J. K. C. Tsui, P. K. W. Chan, K. P. Wang, G. B. Ong
Endoscopic retrograde cholangiopancreatography Endoscopic cannulation was done by one physician with a side-viewing duodenoscope (Olym-
pus JFB). The methodology is conventional (4). Pethidine 50 mg and atropine 0.6 mg were given i.m. 30 min. before the examination. Immediately prior to intubation, diazepam 5-20 mg was given
i.v. and the dose used was one just enough to give rise to a mild degree of drowsiness. Buscopan 40 mg i.v. was given at the same time and again when required for optimal bowel relaxa-
tion for a maximum of three doses. When the use of anticholinergics was undesirable, 1-2 mg i.v. glucagon was used instead. The patient lay in a left lateral position for intubation of the duodenum and was asked to rotate to a prone position once this was achieved. Detailed examination of the stomach was not performed and the endoscope was passed straight to the duodenum, usually within five minutes. Duodenal intubation was successful in all cases. The contrast material employed was 50°/o Hypaque. Aspiration pneumonia was not observed in any one subject after ERCP. After washing with 2°/o Savlon (chlorhexidine gluconate), the duodenoscope and cannulating catheters were routinely immersed in 1°/o Benzalkonium chloride disinfectant (Resiguard) for 10 min. (as advised by the manufacturer) before
use on each patient, care being taken that the biopsy channel was filled with the solution during
immersion. Washings from these instruments were sent for culture frequently at random periods and had grown no organisms.
When the orifice of the papilla could not be identified, a blood culture would be taken at approximately 30 min. from the start of the procedure. If cannulation was still unsuccessful at the end of one hour the examination was given up. In these cases blood cultures were taken immediately after the procedure as well as at 1, 6, 12 and 24 hours afterwards.
The blood was inoculated respectively into a nutrient broth and sodium thioglycolate broth under vacuum in a hydrogen atmosphere for aerobic and anaerobic cultures. Each bottle contained 50 ml of medium and each was inoculated
with 3-5 ml of blood. All units were incubated at 37 °C and inspected daily for 14 days. Table 1 Results of ERCP and distribution of patients with positive blood culture. No. of patients
Normal duct:
biliary pancreatic only
amination and when the catheter was inserted into the orifice of the papilla of Vater at the first attempt at cannulation. This may not mean that the catheter was in the correct position for filling of the bile or pancreatic duct, and subsequent repositioning may be required. 15 min. after successful filling of the bile and/or pancreatic duct
with the contrast material, another blood culture was taken. Successful cannulation was usually accomplished within one hour, average being approximately 20 min. Further blood cultures were carried out at one hour, 6, 12 and 24
hours after the injection of the contrast agent. If fever developed within the next week, further blood cultures were taken at the height of fever.
16 4
1
Obstruction:
Biliary cholangitis only cholangitis + gallstone bile duct stone gallstone only malignancy
pancreatic carcinoma ampullary carcinoma bile duct carcinoma dmlangiocarcinoma
Blood Cultures
Each patient was assessed for sepsis before the procedure by reviewing temperature, white blood cell count and previous tests or procedures (e.g. dental extractions, sigmoidoscopies etc.). None showed evidence of infection. Blood from a peripheral vein was taken for culture before the ex-
No. with positive culture
Pancreatic carcinoma chronic pancreatitis
17 5
10
3
1
1
2 2 1
4
1
1
Endoscopy only
20
Total
83
5
Normal bile and/ or pancreatic duct
There were 20 patients in this group. Blood culture was positive for Alkaligenes faecalis in
aerobic broth in one patient at one hour after injection of contrast material. In this patient, who was investigated because of obscure abdo-
minal pain, a normal pancreatogram was obtained. Because repeated attempts (six in total, 3-5 ml contrast each time) to fill the bile duct resulted only in filling of the pancreatic duct,
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
232
How often does Bacteraemia Occur following ERCP?
233
a pyelogram was eventually obtained (Fig. 1) and the examination was stopped. He developed fever and acute pancreatitis soon after the procedure, which subsided after a week with appro-
priate treatment. A subsequent cholangiogram was normal.
Biliary and/ or pancreatic obstruction
There were 43 patients in this group. Seven
Of these, six had cholangitis, in whom three yielded positive blood culture all at one hour after injection of contrast agent. The three positive cultures were obtained in patients with biliary calculi. In one patient Alkaligenes faecalis was grown, in another Pseudomonas aeruginosa
was obtained and in the third, Escherichia col. The one remaining patient with carcinoma of the pancreas, subsequently proven to be inoperable at surgery, developed a fever of 100°F 48 hours after the procedure. Blood culture taken then yielded Escherichia col. Endoscopy only i.e. failed ERCP
There were 20 patients in this group. No positive culture was obtained in any one patient.
Discussion
Five of 63 patients (7.9%) had bacteraemia after successful ERCP. Bacteraemia does not take place in the 20 patients who had duodenoscopy only, i.e. patients in whom
cannulation of the papilla is unsuccessful after usually one hour of duodenoscopic manipulation. This observation indicates firstly that duodenoscopy alone, unlike sigmoidoscopy (3, 9, 14) and colonoscopy (5), is not likely to result in bacteraemia. Secondly, it suggests that the bacteraemia observed in this series is related to the process of cannulation and injection of contrast material. In the 20 patients with normal ductal system, bacteraemia occured only in
Fig. 1
the present series with this complication. The majority of bacteraemia occurred in patients in whom there was poor drainage of the bile
or pancreatic ducts because of the underlying pathology (three with biliary calculi), one with carcinoma of the pancreas). As the examination cannot be aseptic and
the instruments employed cannot be fully sterilised despite the recommended disinfectant procedures, the intestinal fluid and the
instruments are potential sources of organisms (1, 6). Furthermore obstructed ducts might harbour organisms where drainage cannot be adequate and may be disseminated by the procedure; this may explain why the majority of bacteraemia in this series occured in patients with obstructed ductal systems. It
is interesting to note that in four of the five bacteraemic cases, positive cultures were obtained at one hour after the injection of contrast agent, but not thereafter.
has probably been forced into the circulation
We conclude that the danger of bacteraemia from ERCP is real. Our data further support the need of prophylactic antibiotics
as indicated by the occurrence of a pyelo-
in patients with valvular heart disease
gram. It has been found that pyelogram
undergoing this procedure. However, gram negative bacterial endocarditis developing after a gastroenterological procedure has not
one patient in whom the contrast material
during ERCP is frequently observed in those
patients in whom the pancreatic duct has been subjected, usually inadvertently, to multiple injections with contrast material (2), as in this patient, who is the only one in
been reported (7), although the risk still remains. In places where bile duct stone diseases are common, as in Hong Kong where
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
developed fever within 72 hours of the procedure.
234
recurrent pyogenic cholangitis is a common cause of jaundice (11), the implications of our data are even more pertinent.
5 Dickman, M., R. Farrell, R. Higgs et al.: Colonoscopy associated bacteraemia. Surg. Gynec. Obstet. 142 (1976) 173
6 Elson, C. O., K. Hattori, M. O. Blackstone: Polymicrobial sepsis following endoscopic retrograde cholangiopancreatography. Gastroenterology 69 (1975) 507
Admowledgement
7 Everett 8c Hirschmann: Transient bacteraemia and endo-
We are grateful to Prof. C. T. Huang of the Dept. of Microbiology, University of Hong Kong,
for his advice and help in this study. To Prof. L. Safrany, University of Münster, we owe our sincere gratitude for his introduction of the technique of ERCP to our combined gastrointestinal unit.
carditis prophylaxis. Ann. Rev. Med. 56 (1977) 61
8 Farrell, R. L., M. D. Dickman, R. H. Higgs et al.: Colonoscopy-associated bacteraemia: a clinical entity? Gastroenterology 68 (1974) 1026
9 Le Frock, J. L., C. A. Ellis, J. B. Turdtik et al.: Transient bacteraemia associated with sigmoidoscopy. New Engl. J. Med. 289 (1973) 467
10 Nor(leet, R., D. Mulholland, P. Mitchell: Does bacteraemia follow colonoscopy? Gastroenterology 70 (1976) 20 Arch. Surg. 84 (1962) 199
I Axon, A. T., I. Philips, P. Cotton, S. A. Avery: Disinfection of gastrointestinal fibre endoscopes. Lancet 1974/1, 656
2 Bilbao, M. K., C. T. Dotter, T. G. Lee et al.: Complications of endoscopic retrograde cholangiopancreatography (ERCP). A study of 10,000 cases. Gastroenterology 70 (1976) 314
3 Buchman, E., E. M. Berglund: Bacteraemia following sigmoidoscopy. Amer. Heart J. 60 (1960) 863
4 Cotton, P. B.: Cannulation of the papilla of Vater by endoscopy and retrograde (ERCP). Gut 13 (1972) 1014
cholangiopancreatography
12 Rayforth, R., R. Sorenson, J. Bond: Bacteraemia following colonoscopy. Gastroint. Endosc. 22 (1975) 32
13 Shull, H. J., B. M. Green, S. D. Allen et al.: Bacteraemia with upper gastrointestinal endoscopy. Ann. intern. Med. 83 (1975) 212
14 Unterman, D., M. B. Mil berg, M. Kranis: Evaluation of blood cultures after sigmoidoscpy. New Engl. J. Med. 257 (1957) 773
15 Zimmon, D. S., D. B. Falkenstein, C. Riccobone et al.: Complications of endoscopic retrograde cholangiopancreatography. Analysis of 300 consecutive cases. Gastoenterology 69 (1975) 303
Dr. Shiu Kum Lam, Department of Medicine. University of Hong Kong, Queen Mary Hospital, Hong Kong
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
11 Ong, G. B.: A study of recurrent pyogenic cholangitis.
References
How often does Bacteraemia Occur following Endoscopic Retrograde Cholangiopancreatography S. K. Lam, J. K. C. Tsui Dept. of Med., Univ. of Hong Kong, Queen Mary Hospital, Hong Kong P. K. W. Chan Dept. of Surgery, Univ.of Hong Kong, Queen Mary Hospital, Hong Kong K. P. Wong Institute of Radiology, Queen Mary Hospital, Hong Kong G. B. Ong Dept. of Surgery, Univ. of Hong Kong, Queen Mary Hospital, Hong Kong
Summary
In order to determine the risk of bacteraemia from ERCP, we cultured blood specimens from 83 patients before, during and 15 mm, 1, 6, 12 and 24 hours after the examination as well as in the subsequent week whenever fever occurred.
Wie häufig kommt es nach einer endoskopisch retrograden Cholangiopankreatographie (ERCP) zu einer Bakteriämie? Um Aufschluf3 iiber das Risiko einer Bakteriämie
failed. Of the 20 patients with normal biliary
nach ERCP zu erhalten, wurden bei 83 Patienten vor, während, 1, 6, 12 und 24 Std. nach der Untersuchung sowie bei einer später auftretenden Fieberattacke Blutkulturen angelegt. Bei 20 Patienten, bei denen nur eine Duodenoskopie, aber
and/or pancreatic ducts positive culture was obtained in one patient in whom inadvertent multiple injections of contrast material into the pan-
keine ERCP durchgefiihrt worden war, wurde keine Bakteriämie gefunden. Von 20 Patienten mit normalem Pankreas- und/oder Gallengang
creatic duct had resulted in the occurrence of a pyelogram. Four positive cultures were found
wurden in einem Fall positive Kulturen gesehen. Bei diesem Patienten hatten multiple Kontrast-
amongst the 43 patients in whom an obstructive
mittelinstillationen in den Pankreasgang zum
pathology in the biliary or pancreatic system was present. These data support the need of on heart defects.
Auftreten eines Pyelogramms gefiihrt. 4 positive Kulturen kamen bei 43 Patienten mit obstruktiven Gangveränderungen zur Beobachtung. Die Befunde unterstreicben die Notwendigkeit einer
Key-Words: ERCP, bacteriaemia after ERCP,
antibiotisch'en Therapie.
No bacteraemia was found in the 20 patients who had duodenoscopy only, i.e. in whom ERCP
antibiotic prophylaxis for patients with valvular
duodenoscopy, antibiotic prophylaxis.
Introduction
Transient bacteraemia has been reported after sigmoidoscopy (3, 9, 14), upper gastrointestinal endoscopy (13) and colonoscopy (5), although the occurrence after the latter procedure is still controversial (8, 10, 12). This has important implications in patients
with congenital or acquired valvular heart defects and calls for the need of antibiotic prophylaxis in these individuals when they undergo such procedures.
While cholangitic and pancreatic sepsis represent real hazards in endoscopic retro16 Endoscopy 4/77
grade cbolangiopancreatography (ERCP) (2, 4, 15), information concerning the incidence
of bacteraemia related to this procedure is not available. Methods Patients: In a consecutive series of 87 patients subjected to routine ERCP, blood cultures were carried out in 83 patients. The other four were not studied as they were on antibiotic treatment when the examination was performed. There were 48 males, age ranging from 25 to 78 (mean: 48.9
years) and 35 females, age ranging from 12 to 96 (mean: 62.1 years).
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
(ERCP)?
S. K. Lam, J. K. C. Tsui, P. K. W. Chan, K. P. Wang, G. B. Ong
Endoscopic retrograde cholangiopancreatography Endoscopic cannulation was done by one physician with a side-viewing duodenoscope (Olym-
pus JFB). The methodology is conventional (4). Pethidine 50 mg and atropine 0.6 mg were given i.m. 30 min. before the examination. Immediately prior to intubation, diazepam 5-20 mg was given
i.v. and the dose used was one just enough to give rise to a mild degree of drowsiness. Buscopan 40 mg i.v. was given at the same time and again when required for optimal bowel relaxa-
tion for a maximum of three doses. When the use of anticholinergics was undesirable, 1-2 mg i.v. glucagon was used instead. The patient lay in a left lateral position for intubation of the duodenum and was asked to rotate to a prone position once this was achieved. Detailed examination of the stomach was not performed and the endoscope was passed straight to the duodenum, usually within five minutes. Duodenal intubation was successful in all cases. The contrast material employed was 50°/o Hypaque. Aspiration pneumonia was not observed in any one subject after ERCP. After washing with 2°/o Savlon (chlorhexidine gluconate), the duodenoscope and cannulating catheters were routinely immersed in 1°/o Benzalkonium chloride disinfectant (Resiguard) for 10 min. (as advised by the manufacturer) before
use on each patient, care being taken that the biopsy channel was filled with the solution during
immersion. Washings from these instruments were sent for culture frequently at random periods and had grown no organisms.
When the orifice of the papilla could not be identified, a blood culture would be taken at approximately 30 min. from the start of the procedure. If cannulation was still unsuccessful at the end of one hour the examination was given up. In these cases blood cultures were taken immediately after the procedure as well as at 1, 6, 12 and 24 hours afterwards.
The blood was inoculated respectively into a nutrient broth and sodium thioglycolate broth under vacuum in a hydrogen atmosphere for aerobic and anaerobic cultures. Each bottle contained 50 ml of medium and each was inoculated
with 3-5 ml of blood. All units were incubated at 37 °C and inspected daily for 14 days. Table 1 Results of ERCP and distribution of patients with positive blood culture. No. of patients
Normal duct:
biliary pancreatic only
amination and when the catheter was inserted into the orifice of the papilla of Vater at the first attempt at cannulation. This may not mean that the catheter was in the correct position for filling of the bile or pancreatic duct, and subsequent repositioning may be required. 15 min. after successful filling of the bile and/or pancreatic duct
with the contrast material, another blood culture was taken. Successful cannulation was usually accomplished within one hour, average being approximately 20 min. Further blood cultures were carried out at one hour, 6, 12 and 24
hours after the injection of the contrast agent. If fever developed within the next week, further blood cultures were taken at the height of fever.
16 4
1
Obstruction:
Biliary cholangitis only cholangitis + gallstone bile duct stone gallstone only malignancy
pancreatic carcinoma ampullary carcinoma bile duct carcinoma dmlangiocarcinoma
Blood Cultures
Each patient was assessed for sepsis before the procedure by reviewing temperature, white blood cell count and previous tests or procedures (e.g. dental extractions, sigmoidoscopies etc.). None showed evidence of infection. Blood from a peripheral vein was taken for culture before the ex-
No. with positive culture
Pancreatic carcinoma chronic pancreatitis
17 5
10
3
1
1
2 2 1
4
1
1
Endoscopy only
20
Total
83
5
Normal bile and/ or pancreatic duct
There were 20 patients in this group. Blood culture was positive for Alkaligenes faecalis in
aerobic broth in one patient at one hour after injection of contrast material. In this patient, who was investigated because of obscure abdo-
minal pain, a normal pancreatogram was obtained. Because repeated attempts (six in total, 3-5 ml contrast each time) to fill the bile duct resulted only in filling of the pancreatic duct,
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
232
How often does Bacteraemia Occur following ERCP?
233
a pyelogram was eventually obtained (Fig. 1) and the examination was stopped. He developed fever and acute pancreatitis soon after the procedure, which subsided after a week with appro-
priate treatment. A subsequent cholangiogram was normal.
Biliary and/ or pancreatic obstruction
There were 43 patients in this group. Seven
Of these, six had cholangitis, in whom three yielded positive blood culture all at one hour after injection of contrast agent. The three positive cultures were obtained in patients with biliary calculi. In one patient Alkaligenes faecalis was grown, in another Pseudomonas aeruginosa
was obtained and in the third, Escherichia col. The one remaining patient with carcinoma of the pancreas, subsequently proven to be inoperable at surgery, developed a fever of 100°F 48 hours after the procedure. Blood culture taken then yielded Escherichia col. Endoscopy only i.e. failed ERCP
There were 20 patients in this group. No positive culture was obtained in any one patient.
Discussion
Five of 63 patients (7.9%) had bacteraemia after successful ERCP. Bacteraemia does not take place in the 20 patients who had duodenoscopy only, i.e. patients in whom
cannulation of the papilla is unsuccessful after usually one hour of duodenoscopic manipulation. This observation indicates firstly that duodenoscopy alone, unlike sigmoidoscopy (3, 9, 14) and colonoscopy (5), is not likely to result in bacteraemia. Secondly, it suggests that the bacteraemia observed in this series is related to the process of cannulation and injection of contrast material. In the 20 patients with normal ductal system, bacteraemia occured only in
Fig. 1
the present series with this complication. The majority of bacteraemia occurred in patients in whom there was poor drainage of the bile
or pancreatic ducts because of the underlying pathology (three with biliary calculi), one with carcinoma of the pancreas). As the examination cannot be aseptic and
the instruments employed cannot be fully sterilised despite the recommended disinfectant procedures, the intestinal fluid and the
instruments are potential sources of organisms (1, 6). Furthermore obstructed ducts might harbour organisms where drainage cannot be adequate and may be disseminated by the procedure; this may explain why the majority of bacteraemia in this series occured in patients with obstructed ductal systems. It
is interesting to note that in four of the five bacteraemic cases, positive cultures were obtained at one hour after the injection of contrast agent, but not thereafter.
has probably been forced into the circulation
We conclude that the danger of bacteraemia from ERCP is real. Our data further support the need of prophylactic antibiotics
as indicated by the occurrence of a pyelo-
in patients with valvular heart disease
gram. It has been found that pyelogram
undergoing this procedure. However, gram negative bacterial endocarditis developing after a gastroenterological procedure has not
one patient in whom the contrast material
during ERCP is frequently observed in those
patients in whom the pancreatic duct has been subjected, usually inadvertently, to multiple injections with contrast material (2), as in this patient, who is the only one in
been reported (7), although the risk still remains. In places where bile duct stone diseases are common, as in Hong Kong where
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
developed fever within 72 hours of the procedure.
234
recurrent pyogenic cholangitis is a common cause of jaundice (11), the implications of our data are even more pertinent.
5 Dickman, M., R. Farrell, R. Higgs et al.: Colonoscopy associated bacteraemia. Surg. Gynec. Obstet. 142 (1976) 173
6 Elson, C. O., K. Hattori, M. O. Blackstone: Polymicrobial sepsis following endoscopic retrograde cholangiopancreatography. Gastroenterology 69 (1975) 507
Admowledgement
7 Everett 8c Hirschmann: Transient bacteraemia and endo-
We are grateful to Prof. C. T. Huang of the Dept. of Microbiology, University of Hong Kong,
for his advice and help in this study. To Prof. L. Safrany, University of Münster, we owe our sincere gratitude for his introduction of the technique of ERCP to our combined gastrointestinal unit.
carditis prophylaxis. Ann. Rev. Med. 56 (1977) 61
8 Farrell, R. L., M. D. Dickman, R. H. Higgs et al.: Colonoscopy-associated bacteraemia: a clinical entity? Gastroenterology 68 (1974) 1026
9 Le Frock, J. L., C. A. Ellis, J. B. Turdtik et al.: Transient bacteraemia associated with sigmoidoscopy. New Engl. J. Med. 289 (1973) 467
10 Nor(leet, R., D. Mulholland, P. Mitchell: Does bacteraemia follow colonoscopy? Gastroenterology 70 (1976) 20 Arch. Surg. 84 (1962) 199
I Axon, A. T., I. Philips, P. Cotton, S. A. Avery: Disinfection of gastrointestinal fibre endoscopes. Lancet 1974/1, 656
2 Bilbao, M. K., C. T. Dotter, T. G. Lee et al.: Complications of endoscopic retrograde cholangiopancreatography (ERCP). A study of 10,000 cases. Gastroenterology 70 (1976) 314
3 Buchman, E., E. M. Berglund: Bacteraemia following sigmoidoscopy. Amer. Heart J. 60 (1960) 863
4 Cotton, P. B.: Cannulation of the papilla of Vater by endoscopy and retrograde (ERCP). Gut 13 (1972) 1014
cholangiopancreatography
12 Rayforth, R., R. Sorenson, J. Bond: Bacteraemia following colonoscopy. Gastroint. Endosc. 22 (1975) 32
13 Shull, H. J., B. M. Green, S. D. Allen et al.: Bacteraemia with upper gastrointestinal endoscopy. Ann. intern. Med. 83 (1975) 212
14 Unterman, D., M. B. Mil berg, M. Kranis: Evaluation of blood cultures after sigmoidoscpy. New Engl. J. Med. 257 (1957) 773
15 Zimmon, D. S., D. B. Falkenstein, C. Riccobone et al.: Complications of endoscopic retrograde cholangiopancreatography. Analysis of 300 consecutive cases. Gastoenterology 69 (1975) 303
Dr. Shiu Kum Lam, Department of Medicine. University of Hong Kong, Queen Mary Hospital, Hong Kong
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
11 Ong, G. B.: A study of recurrent pyogenic cholangitis.
References
