Transesophageal echocardiography in patients with esophageal varices.

Transesophageal echocardiography (TEE) has proved invaluable in the evaluation of a number of conditions, including stroke, endocarditis, prosthetic valves, and acute aortic syndromes, as well as in the preoperative and perioperative evaluation of valvular heart disease. The value of TEE must of course be balanced against the risk of performing the procedure. The insertion and manipulation of a transesophageal echocardiographic probe may infrequently cause pharyngeal, esophageal, or gastric trauma. Screening for esophageal pathology by history and review of the medical record is an essential component of evaluation before performing TEE. Patients with esophageal stricture, esophageal cancer, esophageal diverticulum, and recent esophageal surgery are generally considered to have near absolute contraindications for TEE. Esophageal varices have been considered an absolute as well as a relative contraindication to TEE, depending on the center and/or operator. Esophageal varices develop to decompress the hypertensive portal vein circulation that results from obstruction to portal venous outflow; cirrhosis is the most common cause. In prospective studies using fiber optic endoscopy, new varices develop at a rate of 5% in the first year. Twenty-eight percent of patients with cirrhosis have varices at 3 years. It is clear that variceal bleeding carries significant morbidity in patients with cirrhosis. A number of factors have been demonstrated on esophagogastroendoscopy to predict the likelihood of variceal hemorrhage, including the location, size, and appearance of the varices. In addition, several clinical features of individual patients portend a greater variceal bleeding risk. Experienced echocardiography laboratories usually do not consider esophageal varices an absolute contraindication to TEE, but the potential added information should be weighed against the risk for provoking a major upper gastroesophageal bleed. In this issue of the Journal of American Society of Echocardiography, Spier et al report a retrospective analysis of the complications of performing TEE in a series of patients with known gastroesophageal varices. Physicians who perform TEE need to make individualized decisions on the risk/benefit ratio of performing TEE in patients with known or suspected varices. When evaluating the risk, a number of issues should be considered, including the grade of the varices, clinical history of gastroesophageal bleeding, and evidence of coagulopathy (platelet count and international normalized ratio [INR] for prothrombin time). The fact that no reported case of upper variceal bleeding precipitated by TEE can be found in the published literature suggests one of several possibilities: (1) The risk for precipitating gastroesophageal bleeding with TEE is in fact only theoretical. Given the