Bleeding Outcomes Following Transesophageal Echocardiography in Patients With Cirrhosis and Esophageal Varices

Abstract

Despite scant evidence, current guidelines indicate that esophageal varices are a relative contraindication to transesophageal echocardiography (TEE). The aim of this study is to compare the risk of gastrointestinal bleeding following TEE among cirrhotic patients with and without endoscopically-documented esophageal varices. This is a retrospective analysis of patients with cirrhosis who underwent upper endoscopy within 4 years of TEE at five institutions between January 2000 and March 2020. Primary outcome was overt gastrointestinal bleeding. Secondary outcomes were hemoglobin decline by at least 2 g/dL or blood transfusion within 48 hours following TEE. Of the 191 patients, 79 (41.4%) had esophageal varices (30.4% large). No patient experienced a primary outcome. Secondary outcomes occurred in 52 (27.2%): 28 (35.4%) with esophageal varices and 24 (21.4%) without varices. After propensity-score covariate adjustment, the odds ratio for a secondary outcome in patients with esophageal varices was 1.49 (95% confidence interval 0.74-2.99). Restricting analysis to those who underwent endoscopy within 1 year of TEE did not significantly alter results. The risk of a secondary outcome was identical between patients who had upper endoscopy prior (27.5%) versus subsequent (26.7%; P = 1.00) to TEE. Conclusions: Among patients with cirrhosis, there was no overt gastrointestinal bleeding after TEE. The likelihood of a 2 g/dL decline in hemoglobin or blood transfusion within 48 hours following TEE was not significantly higher in patients with esophageal varices after controlling for confounders. Patients who underwent upper endoscopy before TEE did not manifest a lower risk of secondary outcomes versus those who had endoscopy after TEE, suggesting that routine preprocedural endoscopy is of marginal utility. (Hepatology Communications 2020;0:1-10).

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

“…We identified 21 studies comprising 4050 patients evaluating outcomes of TEE in patients with cirrhosis 19‐40 ; TEE was performed intraoperatively prior to liver transplantation in 9 studies ( n = 3015) and for other indications (e.g., cardiopulmonary evaluation or rule out infective endocarditis) in 12 studies ( n = 1035). The clinical characteristics of included studies are reported in Table 1.…”

“…Most studies failed to adequately adjust for confounders that could affect the risk of bleeding. While most studies provided descriptive data on cirrhosis severity (e.g., MELD score, Child Turcotte Pugh class) and parameters of coagulopathy (e.g., platelet count, INR, fibrinogen), only one study performed multivariable analyses of risk of bleeding adjusting for these factors 39 . While some studies reported prior endoscopic findings, prior endoscopic intervention, and/or history of variceal bleeding, only three studies reported the proportion of patients taking nonselective beta‐blockers 22,37,39 .…”

“…Chandra et al was the only study to assess whether patients were up to date on variceal screening per AASLD guidelines, 35 and only one study specifically excluded patients with a history of varices that were banded within 7 days prior to TEE 27 . All but one of the studies 39 failed to include a justification for sample size or report variance in outcomes, and all but nine studies failed to report the loss to follow up.…”

“…While most studies provided descriptive data on cirrhosis severity (e.g., MELD score, Child Turcotte Pugh class) and parameters of coagulopathy (e.g., platelet count, INR, fibrinogen), only one study performed multivariable analyses of risk of bleeding adjusting for these factors. 39 While some studies reported prior endoscopic findings, prior endoscopic intervention, and/or history of variceal bleeding, only three studies reported the proportion of patients taking nonselective beta-blockers. 22,37,39 The use of medications that may increase the risk of bleeding was rarely reported; Most studies assessing the bleeding risk of TEE performed for "other indications" reported endoscopic findings, whereas these data were missing from most studies assessing the risk of bleeding after intraoperative TEE performed during liver transplantation.…”

Safety of Transesophageal Echocardiogram in Patients with Cirrhosis and Esophageal Varices

“…In our retrospective, multicenter study of patients with cirrhosis who underwent TEE in the Mass General Brigham Health system, we identified no instance of overt gastrointestinal hemorrhage, regardless of whether varices were present. 2 We are concerned that the analysis by Hui and Leung likely overestimates the incidence of bleeding with diagnostic TEE by including non-operative therapeutic TEE cases as well as a large study that relied solely on International Classification of Diseases codes for outcome measures. 3 Moreover, in many instances, post-procedure blood loss appears to be principally related to underlying comorbid disease (e.g., cirrhosis) rather than the actual presence of varices, as evidenced by the authors' (and our own) finding that patients with cirrhosis and varices have no higher risk of bleeding than patients with cirrhosis and no varices.…”