GASTROENTEROLOGY
1992;103:1367-1371
CORRESPONDENCE Readers are encouraged to write Letters to the Editor concerning articles that have been published in GASTROENTEROLOGY. Short, general comments are also considered, but use of the Correspondence section for publication of original data in preliminary form is not encouraged. Letters should be typewritten double-spaced and submitted in triplicate.
Septicemia After Endoscopic Retrograde Cholangiopancreatography Dear Sir: Risk factors for septicemia following endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting have been reported by Motte et al. in a retrospective study including 347 patients.’ According to these investigators the main predictive factor for septicemia was the poor quality of biliary drainage following endoscopy. The most frequently found species, Pseudomonas aeruginosa, was significantly associated with formerly performed ERCP in other centers. In our experience, we found 51 cases of septicemia among 2010 patients (2.5%). Septicemia was defined as the positivity of at least two blood cultures within 72 hours after ERCP (blood cultures were not obtained systematically after endoscopic procedures but only in cases with suspected infections). Our study did not include patients who had developed septicemia, cholangitis, fever, or extrabiliary infections within 48 hours before ERCP. The patients who had developed septicemia after ERCP were compared with those in a control group of noninfected patients (n = 193). These control patients were selected at random (one every 10 patients) among all the patients who had undergone ERCP during the same period. The average number of endoscopic or percutaneous transhepatic procedures performed was 1.76+ 1.12in the infected group and 1.25+ 0.70in the control group (P = 0.001). In the infected group, it was the first endoscopic procedure in 28 cases (55%) the second in 14 cases (27%),and the third or more in 9 cases (18%). The prevalence of malignant biliary stricture was higher in the group of infected patients than in the control patients (80% vs. 23%; P = 0.0001). In the infected group, biliary stenting had been performed in 35 cases. Biliary drainage was considered complete in 16 cases (46%) and incomplete in 19 cases (54%). Our septicemic rate following biliary stenting (8.9%) was comparable with the figure reported by Motte et al.’ (10%). In both univariate and multivariate analysis, we have looked for infectious risk factors following ERCP: incomplete biliary drainage (P = 0.009) and number of ERCP sessions (P = 0.001) were found to be predictive factors for infection, in agreement with these authors. Moreover, malignancy (P = 0.0001) as well as ultrasound dilatation of the biliary tract (P < 0.001)were also significant predictive factors. P. aeruginosa was also the most frequently found species (accounting for 80% of positive blood cultures and 23% of positive bile cultures), but, unlike these authors, its prevalence was not higher in patients having formerly undergone recent ERCP in other centers. Therefore, in agreement with Motte et al.,‘.z we believe that if malignancy is suspected, antibiotic prophylaxis with anti-P. aeruginosa activity should be administered before ERCP. If biliary drainage is incomplete after a first ERCP, this antibiotherapy should be continued until obstruction is relieved. This antibiotic prophylaxis is likely to reduce the rate of septicemia following
ERCP in patients with malignant drainage is difficult to obtain.
strictures
in whom complete
P. NOVELLO, M.D. H. HAGEGE, M.D. C. BUFFET,PH.D. J.FRITSCH,M.D. A. CHOURY, M.D. J.P.ETIENNE,PH.D. Service des Maladies du Foie et de I’AppareiI Digestif, Hopital de Bicdtre Kremlin Bicdtre, France 1. Motte S, Deviere J, Dumonceau JM, Serruys E, Thys JP, Cremer M. Risk factors for septicemia following endoscopic biliary stenting. Gastroenterology 1991;101:1374-1381. 2. Deviere J, Motte S, Dumonceau JM, Serruys E, Thys JP, Cremer M. Septicemia after endoscopic retrograde cholangiopancreatography. Endoscopy 1990;22:72-75.
Quantitative Discrimination B and C Receptors
of Glomerular
Dear Sir: Morgan et al. recently investigated binding of atria1 natriuretic factor (ANF) on freshly isolated glomeruli of bile duct-ligated (BDL) rats without ascites and sham-operated controls.’ They found a single ANF binding site with an affinity of about 5 X lo-” mol/L in both BDL rats and controls with a higher receptor density in the BDL rats (1221+249vs.931 f 209 fmol/mgprotein). At the same time they found no difference in cyclic guanosine monophosphate (GMP) generation of isolated glomeruli between BDL rats and controls. They conclude that their “findings of increased density of total receptors with no change in guanylate cyclasecontaining receptors suggest that the density of C receptors is increased in glomeruli from cirrhotic rats.” The binding sites found by the authors had an affinity of about 5 X lo-" mol/L, well in the range that we have previously reported for glomerular C receptors. Unfortunately, they did not characterize the nature of their binding site, e.g., by affinity crosslinking and sodium dodecyl sulfate gel electrophoresis. Following ANF administration, the authors observed cyclic GMP production by glomeruli, suggesting the existence of B receptors. Why were they unable to demonstrate B receptors in their binding studies? Referring to our previous work,2 Morgan et al. suggest that differences in methodology should be responsible, namely their using freshly isolated intact glomeruli whereas our experiments were performed on frozen glomerular membranes. At the time of the submission of Morgan’s paper, we had published a detailed investigation on optimization of glomerular ANF binding studies.3 At various durations and temperatures of incubation we had compared binding of ANF to intact glomeruli as opposed to frozen membranes. We were able to determine quantitatively both B and C receptors in glomeruli as well as in glomerular membranes. However, interassay variations were lower and specific binding was higher with the membrane preparation than with the glomer-
1992;103:1367-1371
CORRESPONDENCE Readers are encouraged to write Letters to the Editor concerning articles that have been published in GASTROENTEROLOGY. Short, general comments are also considered, but use of the Correspondence section for publication of original data in preliminary form is not encouraged. Letters should be typewritten double-spaced and submitted in triplicate.
Septicemia After Endoscopic Retrograde Cholangiopancreatography Dear Sir: Risk factors for septicemia following endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting have been reported by Motte et al. in a retrospective study including 347 patients.’ According to these investigators the main predictive factor for septicemia was the poor quality of biliary drainage following endoscopy. The most frequently found species, Pseudomonas aeruginosa, was significantly associated with formerly performed ERCP in other centers. In our experience, we found 51 cases of septicemia among 2010 patients (2.5%). Septicemia was defined as the positivity of at least two blood cultures within 72 hours after ERCP (blood cultures were not obtained systematically after endoscopic procedures but only in cases with suspected infections). Our study did not include patients who had developed septicemia, cholangitis, fever, or extrabiliary infections within 48 hours before ERCP. The patients who had developed septicemia after ERCP were compared with those in a control group of noninfected patients (n = 193). These control patients were selected at random (one every 10 patients) among all the patients who had undergone ERCP during the same period. The average number of endoscopic or percutaneous transhepatic procedures performed was 1.76+ 1.12in the infected group and 1.25+ 0.70in the control group (P = 0.001). In the infected group, it was the first endoscopic procedure in 28 cases (55%) the second in 14 cases (27%),and the third or more in 9 cases (18%). The prevalence of malignant biliary stricture was higher in the group of infected patients than in the control patients (80% vs. 23%; P = 0.0001). In the infected group, biliary stenting had been performed in 35 cases. Biliary drainage was considered complete in 16 cases (46%) and incomplete in 19 cases (54%). Our septicemic rate following biliary stenting (8.9%) was comparable with the figure reported by Motte et al.’ (10%). In both univariate and multivariate analysis, we have looked for infectious risk factors following ERCP: incomplete biliary drainage (P = 0.009) and number of ERCP sessions (P = 0.001) were found to be predictive factors for infection, in agreement with these authors. Moreover, malignancy (P = 0.0001) as well as ultrasound dilatation of the biliary tract (P < 0.001)were also significant predictive factors. P. aeruginosa was also the most frequently found species (accounting for 80% of positive blood cultures and 23% of positive bile cultures), but, unlike these authors, its prevalence was not higher in patients having formerly undergone recent ERCP in other centers. Therefore, in agreement with Motte et al.,‘.z we believe that if malignancy is suspected, antibiotic prophylaxis with anti-P. aeruginosa activity should be administered before ERCP. If biliary drainage is incomplete after a first ERCP, this antibiotherapy should be continued until obstruction is relieved. This antibiotic prophylaxis is likely to reduce the rate of septicemia following
ERCP in patients with malignant drainage is difficult to obtain.
strictures
in whom complete
P. NOVELLO, M.D. H. HAGEGE, M.D. C. BUFFET,PH.D. J.FRITSCH,M.D. A. CHOURY, M.D. J.P.ETIENNE,PH.D. Service des Maladies du Foie et de I’AppareiI Digestif, Hopital de Bicdtre Kremlin Bicdtre, France 1. Motte S, Deviere J, Dumonceau JM, Serruys E, Thys JP, Cremer M. Risk factors for septicemia following endoscopic biliary stenting. Gastroenterology 1991;101:1374-1381. 2. Deviere J, Motte S, Dumonceau JM, Serruys E, Thys JP, Cremer M. Septicemia after endoscopic retrograde cholangiopancreatography. Endoscopy 1990;22:72-75.
Quantitative Discrimination B and C Receptors
of Glomerular
Dear Sir: Morgan et al. recently investigated binding of atria1 natriuretic factor (ANF) on freshly isolated glomeruli of bile duct-ligated (BDL) rats without ascites and sham-operated controls.’ They found a single ANF binding site with an affinity of about 5 X lo-” mol/L in both BDL rats and controls with a higher receptor density in the BDL rats (1221+249vs.931 f 209 fmol/mgprotein). At the same time they found no difference in cyclic guanosine monophosphate (GMP) generation of isolated glomeruli between BDL rats and controls. They conclude that their “findings of increased density of total receptors with no change in guanylate cyclasecontaining receptors suggest that the density of C receptors is increased in glomeruli from cirrhotic rats.” The binding sites found by the authors had an affinity of about 5 X lo-" mol/L, well in the range that we have previously reported for glomerular C receptors. Unfortunately, they did not characterize the nature of their binding site, e.g., by affinity crosslinking and sodium dodecyl sulfate gel electrophoresis. Following ANF administration, the authors observed cyclic GMP production by glomeruli, suggesting the existence of B receptors. Why were they unable to demonstrate B receptors in their binding studies? Referring to our previous work,2 Morgan et al. suggest that differences in methodology should be responsible, namely their using freshly isolated intact glomeruli whereas our experiments were performed on frozen glomerular membranes. At the time of the submission of Morgan’s paper, we had published a detailed investigation on optimization of glomerular ANF binding studies.3 At various durations and temperatures of incubation we had compared binding of ANF to intact glomeruli as opposed to frozen membranes. We were able to determine quantitatively both B and C receptors in glomeruli as well as in glomerular membranes. However, interassay variations were lower and specific binding was higher with the membrane preparation than with the glomer-
