Safety of performing transoesophageal echocardiography in patients with oesophageal varices

Abstract

IntroductionOesophageal varices (EV) are one of the complications of liver cirrhosis that carries a risk of rupture and bleeding. The safety of performing transesophageal echocardiography (TEE) in patients with pre-existing EV is not well described in literature. Therefore, this retrospective study has been conducted to evaluate the safety of preforming TEE in this group of patients.MethodsThe study population was extracted from the 2016 Nationwide Readmissions Data using International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System for EV, TEE and in-hospital outcomes. Study endpoints included in-hospital all-cause mortality, hospital length of stay, postprocedural gastrointestinal bleeding and oesophageal perforation.ResultsA total of 81 328 discharges with a diagnosis of EV were identified, among which 242 had a TEE performed during the index hospitalisation. Mean age was 58.3 years, 36.6% female. In comparison to the no-TEE group, the TEE group was associated with comparable in-hospital all-cause mortality (7.0% vs 6.7%, p=0.86) and bleeding (0.9% vs 1.1%, p=0.75); however, TEE group was associated with longer hospital stay (14.9 days vs 6.9 days, p<0.01). There were no reported oesophageal perforations.ConclusionsTEE is not a common procedure performed in patients with pre-existing EV. TEE seems to be a safe diagnostic tool for evaluation of heart diseases in this group of patients.

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

“…The only large database study showed no difference in rates of in-hospital bleeding between patients with esophageal varices who did or did not undergo TEE, with the caveat that patient characteristics and endpoints were based solely on diagnosis codes and were not clinically validated. (12) In line with prior reports, no patient in our study experienced a primary outcome of overt variceal hemorrhage. This finding is somewhat intuitive, as bleeding from varices generally is a consequence of vessel rupture from elevated portal pressure as opposed to external injury.…”

“…The only large database study showed no difference in rates of in‐hospital bleeding between patients with esophageal varices who did or did not undergo TEE, with the caveat that patient characteristics and endpoints were based solely on diagnosis codes and were not clinically validated. ( 12 )…”

“…( 2 ) Similarly, an analysis of the 2016 Nationwide Readmissions Data reported that, of hospitalized patients discharged with a diagnosis of esophageal varices, the 242 (0.3%) who underwent TEE had similar rates of gastrointestinal bleeding (~1%) as those who did not, although findings were based solely on diagnosis codes. ( 12 ) No study has examined the influence of variceal grade on bleeding risk or whether endoscopic screening of patients with cirrhosis prior to performing TEE reduces the risk of postprocedural bleeding. For these reasons, the aim of the present study was to assess whether the presence and grade of endoscopically verified esophageal varices increases the risk of hemorrhage following TEE in patients with cirrhosis, and whether endoscopic screening before performing TEE reduces bleeding risk.…”

“…(7)(8)(9) As patients with cirrhosis are at generally higher risk of adverse procedural outcomes, including hemorrhage, (10,11) it is notable that only two studies of variceal bleeding post TEE included a comparator group. (12) A retrospective analysis of intra-operative TEE at the time of liver transplantation found no difference in blood transfusion requirements between those with or without esophageal varices, and noted a single case of overt bleeding in a patient who had undergone a prior transjugular intrahepatic portosystemic shunt (TIPS) procedure and had no varices on autopsy. (2) Similarly, an analysis of the 2016 Nationwide Readmissions Data reported that, of hospitalized patients discharged with a diagnosis of esophageal varices, the 242 (0.3%) who underwent TEE had similar rates of gastrointestinal bleeding (~1%) as those who did not, although findings were based solely on diagnosis codes.…”

Safety of Transesophageal Echocardiogram in Patients with Cirrhosis and Esophageal Varices

“…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. We also found no difference in bleeding outcomes (defined as hemoglobin decline by at least 2 g/ dL or blood transfusion within 48 hours of TEE) when endoscopy was performed prior to versus post TEE, arguing against the utility of routine pre-procedure endoscopic screening of cirrhotic patients.We wish to highlight that available data do not support the authors' suggestion that correction of coagulopathy prior to TEE is an effective way to reduce bleeding risk.…”