Annual Scientific Meeting
Introduction: The presence of esophageal varices is considered a relative contraindication to transesophageal echocardiography (TEE) by some professional societies, so gastroenterologists are often consulted to perform upper endoscopy prior to TEE in patients with cirrhosis. Our study’s aim was to perform a systematic review and meta-analysis to quantify the risk of bleeding complications in cirrhosis patients following TEE.
Methods: Two reviewers searched MEDLINE and EMBASE databases from January 1992 to January 2019 for studies reporting bleeding complications following TEE in patients with cirrhosis. Data was extracted by two authors using standardized forms. The pooled incidence rate was calculated using the DerSimonian and Laird method for a random-effects model. The modified Newcastle-Ottawa Scale (NOS) was used to assess study quality. This study was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines.
Results: We identified 16 studies meeting inclusion criteria comprising 3415 unique cirrhosis patients. Nine studies (n=3009) assessed risk of intraoperative TEE during LT and 7 studies (n=406) included cirrhosis patients undergoing TEE for other indications; upper endoscopy was performed prior to TEE in 3 out of 9 and 7 out of 7 of those studies, respectively. The pooled risk of bleeding complications post-TEE was 1.0% (95%CI 0.0 – 2.0%) across all studies. The proportion of patients with bleeding complications was similar among patients undergoing intraoperative TEE during LT compared to those undergoing TEE for other reasons (1.1% vs 2.2%, p=0.06). Further, bleeding rates were similar among patients in the subgroup of studies with mean MELD > 18 compared to studies with mean MELD < 18 (1.9% vs 1.3%, p = 0.31). Three studies had NOS quality scores < 5, 6 had a score of 5–7, and 7 studies had quality scores >7. Overall, the cohorts were representative and included patients with various etiologies of cirrhosis, though most were retrospective in design and lacked a control group. Detailed data on patient-level factors impacting bleeding complications (including degree of liver dysfunction and coagulopathy) were inconsistently reported and limited across studies.
Discussion: There is a low risk of bleeding complications in cirrhosis patients following TEE, suggesting TEE is safe and risk stratification with upper endoscopy may not be necessary.