Safety of Transesophageal Echocardiogram in Patients with Cirrhosis and Esophageal Varices

Abstract

We read with interest the review article and meta-analysis by Hui and Leung 1 regarding the bleeding risk of transesophageal echocardiogram (TEE) performed in patients with esophageal varices. We concur with the authors' conclusion that TEE is associated with a low incidence of gastrointestinal bleeding in patients with gastroesophageal 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. 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. Current guidance from the American Association for the Study of Liver Diseases is that routine correction of platelets, international normalized ratio, or fibrinogen is unnecessary in patients with cirrhosis undergoing invasive procedures with high risk of bleeding. 4 Furthermore, we disagree with the authors' proposition that available data are insufficient to warrant recommendations or guideline changes. The weight of evidence unequivocally indicates that there is minimal risk of bleeding from TEE in patients with gastroesophageal varices and that any potential harm is typically far outweighed by the hazards of not performing the procedure. Indeed, as long as esophageal varices are considered a contraindication to TEE, the large-scale, high-quality studies on this topic that Hui and Leung endorse are unlikely to be performed. Case in point, in our analysis, 2 out of nearly 44,000 patients undergoing TEE over a 20-year period, only 79 (0.18%) had cirrhosis and esophageal varices.In summary, we believe that current data support the following guidance: (1) The presence or suspicion of esophageal varices should not delay urgent/emergent TEE and does not warrant pre-procedure endoscopy. (2) Performance of TEE should not be delayed in patients with esophageal varices who are receiving appropriate variceal prophylaxis. (3) In patients at risk for esophageal vari...

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“…The finding is supported by the recent systematic review and meta‐analysis that showed that the incidence of post‐TEE bleeding in patient with varices was low (0.84%, 95% confidence interval [CI] 0.34%–1.56%) and the bleeding risk was comparable between patients with and those without varices (risk difference, 0.26%; 95% CI, −0.80% to 1.32%; I 2 = 0%; p = 0.88) 11 . Based on the current findings, the presence or suspicion of esophageal varices should not delay urgent TEE and does not warrant upper endoscopy before procedure 12 …”

“…11 Based on the current findings, the presence or suspicion of esophageal varices should not delay urgent TEE and does not warrant upper endoscopy before procedure. 12 To date, there is no specific treatment recommendation regarding the preferred antibiotic or duration for IE treatment in cirrhosis, particularly in LT candidates. A systematic review reported that aminoglycosides, vancomycin, and cephalosporins were the antimicrobials most frequently used for treatment of IE in cirrhosis.…”