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

INTRODUCTION

Transesophageal echocardiography (TEE) is an important diagnostic procedure that is specifically useful in patients with advanced cirrhosis since this group of patients frequently has cirrhotic cardiomyopathy with varying degrees of heart failure. However, the safety of TEE in patients with cirrhosis and gastroesophageal varices has remained uncertain. Therefore, international guidelines, which are based mainly on expert opinion, suggest that esophageal varices are a relative contraindication to TEE.

Therefore, the purpose of this systematic review and metanalysis was to determine the pooled incidence of gastrointestinal bleeding after TEE in patients with gastroesophageal varices. The secondary objectives of this metanalysis were to compare bleeding risks between patients with and those without gastroesophageal varices and to determine the incidence of TEE-related esophageal perforation and mortality.

METHODS

A systematic literature search was performed on Embase, MEDLINE, and the Cochrane Library using the following terms and their synonyms or Medical Subject Heading terms: ‘‘transesophageal echocardiography,’’ ‘‘esophageal varices,’’ and ‘‘bleeding.’’ Articles describing the incidence of postprocedural bleeding after TEE in patients with gastroesophageal varices were included. Nonoriginal articles, case reports, and conference proceedings were excluded.

Two reviewers independently screened the articles for eligibility for inclusion. Data were extracted from the included trials independently.

The level of evidence was Recommendation, Assessment, assessed using the Development, and (GRADE) approach, which include the domains of risk of bias, imprecision, inconsistency, indirectness, and other considerations.

RESULTS

Out of five hundred and sixty-nine articles, which were originally identified from systematic literature search, ten articles were included in the meta-analysis. These ten articles reported ten independent studies that were published between 1996 and 2021. The study sample sizes ranged from 14 to 287 patients, examining a total of 908 patients.

The indications for TEE in the included studies were diagnostic echocardiography in six studies and intraoperative monitoring for liver transplantation in three studies. Diagnostic echocardiography was defined as echocardiography indicated for diagnosis of valvular vegetations or structural heart lesions. One study involved a mixed cohort of patients indicated for diagnostic echocardiography or intraoperative monitoring.

The reported incidence of gastrointestinal bleeding after TEE in patients with varices ranged from 0% to 4.35%. The overall pooled weighted gastrointestinal bleeding incidence among all 10 studies (908 patients) was 0.84% (95% CI, 0.34%-1.56%). When the study with high risk of bias was excluded, the remaining nine studies had a pooled bleeding incidence of 0.76% (95% CI, 0.28%-1.46%).

When stratified by indication for TEE, the pooled incidence of bleeding was 0.68% (95% CI, 0.11%-1.63%) in 503 patients undergoing intraoperative TEE and 1.03% (95% CI, 0.23%2.29%) in 405 patients undergoing diagnostic TEE.

CONCLUSIONS

The authors concluded that based on this meta-analysis, TEE in patients with gastroesophageal varices is associated with a low incidence of postprocedural bleeding (1.03% for diagnostic TEE, 0.68% for intraoperative TEE, and 0.84% overall).

They also commented that bleeding risk was not significantly different between patients with and without gastroesophageal varices.

Finally, in this meta-analysis there were no reported incidences of TEE-related esophageal perforation or death.

It is important to report, though, that most included studies had moderate to high risk for bias, and the overall level of evidence was low.

The author concluded that the available data are insufficient to lead to recommendations or guideline changes, and recommended to conduct large-scale high-quality studies to confirm the safety of TEE in patients with gastroesophageal varices.