Two cases of variceal haemorrhage during living-donor liver transplantation

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.

Inferolateral ST-segment elevation with use of Sengstaken-Blakemore tube for variceal bleeding during orthotopic liver transplantation

Oesophageal balloon tamponade tubes are a rare cause of ST-segment elevation (STE), thought to result from extrinsic compression of coronary arteries. This case describes STE following the use of a Sengstaken-Blakemore tube (SBT) under traction for management of bleeding oesophageal varices during orthotopic liver transplantation. This case is the first to report a significant troponin rise with STE indicative of myocardial injury following the use of SBT. Interestingly, we found that releasing traction from the SBT resulted in resolution of STE within minutes, suggesting that SBT traction may reversibly impede coronary perfusion. We recommend vigilant monitoring of patients following SBT insertion and for clinicians to consider that SBT traction may impair coronary perfusion and result in myocardial injury in patients without pre-existing coronary artery disease.