Polymicrobial Multiple Intraabdominal Infections - A Rare Complication of Colonoscopy in a Cirrhotic Patient

Abstract

Case Description: A 58-year-old male with a history of HCV and alcohol related advanced cirrhosis, presented with altered mental status and right upper quadrant pain, three days following upper and lower endoscopy. The endoscopy showed hemorrhoids and minimal gastritis and no interventions were performed. Diagnostic work-up upon admission showed elevated white blood cell count. CT abdomen showed multiple liver abscesses, which were partially drained and grew Streptococcus anginosus and Staphylococcus epidermidis. There were no other intra-abdominal fluid collections or abscesses, no features suggestive of bowel perforation on imaging. Blood cultures grew E. coli. His condition gradually deteriorated despite treatment with appropriate antibiotics. Repeat CT scan 10 days later showed right upper lobe pneumonia, bilateral pleural effusion along with persistent liver abscesses and new ascites. Paracentesis revealed an exudate with WBC count of 8125 with 94% neutrophils and grew Klebsiella pneumoniae. Antibiotics were adjusted according to sensitivities. However, his condition continued to deteriorate and he finally died of severe sepsis and multi-organ dysfunction. Discussion: There is a wide variation in the rate of bacteremia after various endoscopic procedures ranging from 2 to 45% based on type of procedure performed. They occur predominantly following interventional procedures. To our knowledge, there have only been two cases of bacterial peritonitis following colonoscopy in patients undergoing continuous ambulatory peritoneal dialysis and 2 other instances in patients with cirrhosis and ascites. Septicemia has been reported in only 4 cases after colonoscopy. These include 2 patients with cirrhosis and ulcerative colitis who developed gram negative septicemia; a patient who underwent splenectomy and was taking corticosteroids developed septicemia with Flavobacterium meningosepticum and Escherichia coli; and Listeria in a patient being treated with ACTH for ulcerative colitis. Conclusions: Patients with cirrhosis have a higher rate of infectious complications, likely due to decreased compliment levels, impaired neutrophil chemotaxis, lymphocyte dysfunction and immunoglobulin dysfunction, combined with portal hypertensive colopathy due to venous congestion. In summary, infectious complications following diagnostic endoscopies in cirrhotics are rare but can be severe and life threatening, even without obvious signs of bowel perforation.