SAN FRANCISCO – Transesophageal echocardiogram does not cause bleeding in cirrhotic patients with small varices or with large varices that have been previously treated, according to Australian researchers at the annual meeting of the American Association for the Study of Liver Diseases.
In a retrospective case series, 75 patients with varices had undergone 78 transesophageal echocardiograms (TEEs), most of which were done to rule out endocarditis or to monitor hemodynamic stability during liver transplantation. A total of 62 patients (83%) had esophageal varices, and 19 (25%) had gastric varices.
About half of the esophageal varices were larger than 5 mm, sometimes with red whale marks, spurting, or other endoscopic stigmata. In a few cases, the varices filled up more than half of the esophageal lumen. Large varices were treated before TEE, usually by banding or transjugular intrahepatic portosystemic shunt.
Twenty-two percent (14) of the esophageal varices and 33% (6) of the gastric varices were treated before TEE. The rest were deemed too small to need treatment.
None of the patients bled from the TEE procedure, which was done in one case just a week after banding, but in most cases was done several months later, said investigator and gastroenterologist Lucy Lim.
It’s an important finding because the theoretical bleeding risk means that "there’s still a lot of controversy" about whether TEEs are safe in patients with varices. Cardiologists – who most often do the procedure – sometimes "outright refuse if there are even small varices. They are the ones we need to convince," said Dr. Lim of the gastroenterology and liver transplant unit at the Austin Hospital in Melbourne.
Almost 70% (52) of the patients were men (average age, 54 years). The majority had Childs-Pugh A cirrhosis; the rest had Childs-Pugh B. The cirrhosis was attributed to hepatitis C or alcohol consumption in most cases. Varices are a common complication of cirrhosis-induced portal vein hypertension.
A smaller 2009 case series also found that TEEs were safe in patients with varices (J. Am. Soc. Echocardiogr. 2009;22:396-400). A comprehensive review of the issue was published in 2010 (J. Am. Soc. Echocardiogr. 2010;23:1115-27).
Dr. Lim said she had no relevant financial disclosures.