Bleeding Risk in Patients with Cirrhosis Undergoing Transesophageal Echocardiography: 6-Year Experience from Parkland Health and Hospital System

Role of endoscopic evaluation prior to diagnostic transesophageal echocardiography: Is it necessary?

Background and Aim

Esophagogastroduodenoscopy (EGD) is often performed prior to transesophageal echocardiogram (TEE) to evaluate for esophageal pathologies. Although TEE is a safe procedure, some contraindications exist, such as esophageal varices. The incidence of bleeding with TEE is <0.01%, which questions the need for this routine invasive procedure prior to TEE. We sought to characterize patients in whom pre‐TEE endoscopy was requested to determine its clinical utility and identify those that would most benefit.

Methods

We retrospectively studied patients who underwent EGD for TEE clearance between January 2014 and October 2019. We assessed how often EGD changed management and complications after TEE in those with EGD abnormalities.

Results

Eighty‐three patients were included. Twenty‐three percent had prior GI bleed, 63% had cirrhosis, 18% had known varices, and 7% had prior variceal bleed. The most common EGD findings were varices (33%). Eighty‐one percent proceeded with TEE. Reasons for TEE deferral included varices (12.5%), high‐risk bleeding lesion (12.5%), and mechanical abnormality (12.5%). In the majority (37.5%), TEE was deemed no longer indicated. No patient undergoing TEE had significant hemoglobin drop or overt bleeding. The most common reason for not performing TEE was unrelated to EGD findings: lack of ongoing indication for TEE.

Conclusion

Based on our study, EGD is likely not needed for TEE clearance in patients with varices or prior GI bleed. Given that data are limited in patients with abnormalities such as strictures, EGD may still be warranted for these patients. Further studies to identify which patients will benefit from pre‐TEE endoscopy are warranted.

Systematic review with meta-analysis: incidence of variceal hemorrhage in patients with cirrhosis undergoing transesophageal echocardiography

BACKGROUND

The presence of esophageal varices is considered a relative contraindication to transesophageal echocardiography (TEE) by cardiology professional societies, so gastroenterologists are often consulted to perform upper endoscopy prior to TEE in patients with cirrhosis.

AIM

To perform a systematic review to quantify the risk of bleeding complications in patients with cirrhosis following TEE.

METHODS

Two reviewers searched Ovid MEDLINE, MEDLINE In-Process and EMBASE databases from January 1992 to May 2021 for studies reporting bleeding complications from TEE in patients with cirrhosis. We calculated the pooled incidence rate of bleeding events using the metaprop command with a random effect model.

RESULTS

We identified 21 studies comprising 4050 unique patients with cirrhosis; 9 studies (n = 3015) assessed the risk of intraoperative TEE during liver transplant (LT) and 12 studies (n = 1035) assessed bleeding risk in patients undergoing TEE for other indications. The pooled incidence of bleeding post-TEE was 0.37% (95% CI 0.04-0.94%) across all studies. Bleeding complications were low among patients undergoing TEE during LT as well as those undergoing TEE for other diagnostic reasons (0.97% vs. 0.004%) and among studies with mean MELD >18 compared to those with mean MELD <18 (0.43% vs. 0.08%). Few studies had a comparator arm, and data on patient-level factors impacting bleeding complications (including degree of liver dysfunction and coagulopathy) were limited across studies.

CONCLUSIONS

The risk of bleeding complications following TEE is low in patients with cirrhosis, suggesting TEE is safe and risk stratification with upper endoscopy may not be necessary.

Incidence of Gastrointestinal Bleeding after Transesophageal Echocardiography in Patients with Gastroesophageal Varices: A Systematic Review and Meta-Analysis

BACKGROUND

Transesophageal echocardiography (TEE) is useful for cardiac assessment and intraoperative monitoring. However, the safety of TEE in patients with cirrhosis and gastroesophageal varices has remained uncertain. The aim of this meta-analysis was to determine the incidence of gastrointestinal bleeding after TEE in patients with varices. The secondary objectives were to compare bleeding risks between patients with and without varices and to determine the incidence of TEE-related esophageal perforation and mortality.

METHODS

A systematic literature search was conducted on MEDLINE, Embase, and the Cochrane Library using the terms "transesophageal echocardiography," "varices," "bleeding," and related terms. Articles describing the incidence of post-TEE bleeding in patients with varices were included. Non-English-language articles were excluded. Risk of bias and level of evidence were assessed using validated scales. The pooled weighted incidence of gastrointestinal bleeding and the risk difference in bleeding were calculated using a random-effects model.

RESULTS

Five hundred and sixty-nine articles were identified initially, and 10 articles (comprising of 908 patients) were included. The incidence of post-TEE bleeding in patients with varices was 0.84% (95% CI, 0.34% to 1.56%). When stratified by indication for TEE, the pooled incidence of bleeding was 0.68% (95% CI, 0.11% to 1.63%) for intraoperative TEE and 1.03% (95% CI, 0.23% to 2.29%) for diagnostic TEE. No cases of esophageal perforation or mortality were reported. Six studies included comparator groups of patients without varices, and the bleeding risk was comparable between patients with and those without varices (risk difference, 0.26%; 95% CI, -0.80% to 1.32%; I² = 0%; P = .88). Eight studies had moderate or high risk for bias, and the overall level of evidence was low.

CONCLUSIONS

TEE appears to be associated with low gastrointestinal bleeding incidence in patients with gastroesophageal varices. Nonetheless, results should be treated with caution because of bias and low level of evidence. Large-scale high-quality studies will be required to confirm the safety of TEE in patients with gastroesophageal varices.