Incidence of gastrointestinal bleeding after transesophageal echocardiography in patients with gastroesophageal varices: A systematic review and meta-analysis
Department of Medicine, The University of Hong Kong, Hong Kong. Electronic address: huirex@connect.hku.hk. Department of Anaesthesiology, Queen Mary Hospital, Hong Kong.
Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography. 2021
BACKGROUND Transesophageal echocardiography (TEE) is useful for cardiac assessment and intraoperative monitoring. However, the safety of TEE in cirrhotic patients with gastroesophageal varices has remained uncertain. This meta-analysis aims to determine the incidence of gastrointestinal bleeding after TEE in patients with varices. The secondary objectives are to compare the bleeding risks between patients with and without varices; and to determine
the incidences of TEE-related esophageal perforation and mortality. METHODS Systematic literature search was conducted on MEDLINE, EMBASE and Cochrane Database using the terms "Transesophageal echocardiography", "Varices", "Bleeding", and related terms. Articles describing the incidence of post-TEE bleeding in patients with varices were included. Non-English articles were excluded. Risk of bias and level of evidence were assessed through validated scales. Pooled weighted incidence of gastrointestinal bleeding and risk difference in bleeding were calculated with a random effects model. RESULTS 569 articles were identified initially, and 10 articles (comprising of 908 patients) were included. The incidence of post-TEE bleeding in patients with varices was 0.84% (95% CI 0.34%-1.56%). When stratified by TEE indication, the pooled incidence of bleeding was 0.68% (95% CI 0.11%-1.63%) in intraoperative TEE; and 1.03% (95% CI 0.23%-2.29%) in diagnostic TEE. No cases of esophageal perforation or mortality were reported. Six studies included a comparator group of patients without varices, and the bleeding risk was comparable between patients with and without varices (risk difference 0.26%; 95% CI -0.80%-1.32%; I2=0%, p=0.88). Eight studies had moderate or high risk of bias, and overall level of evidence was low. CONCLUSION TEE appears to be associated with low gastrointestinal bleeding incidence in patients with gastroesophageal varices. Nonetheless, results should be treated with caution due to bias and low level of evidence. Large-scale high-quality studies will be required to confirm the safety of TEE in patients with gastroesophageal varices.
