Abstract
Transesophageal echocardiogram (TEE) is an invasive test that involves advancement of an ultrasound probe to the esophagus for cardiac evaluation with no direct visualization of the esophageal mucosa. Safety of TEE in patients with cirrhosis without prior esophagogastroduodenoscopy (EGD) for evaluation of esophageal varices poses a major concern for cardiologists. We present two cases where tandem EGD-TEE were performed as a multidisciplinary and patient-centered approach to the care of cirrhotic patients in need of EGD and TEE evaluation. 43-year-old Caucasian male with history of alcohol induced compensated cirrhosis who presented with sepsis and positive blood cultures for methicillin-resistant Staphylococcus aureus (MRSA). His blood cultures continued to be positive for MRSA at day 4 despite treatment with vancomycin and TEE was indicated to rule out infective endocarditis. The TEE equipments brought into the endoscopy suite, and the cardiology and gastroenterology (GI) teams were present for both EGD and TEE procedures. Upper endoscopy was performed to evaluate for esophageal varices. He was found to have small esophageal varices that completely flattened with air insufflation. TEE was then performed with no concern for post-procedural gastrointestinal bleeding, and no clinical evidence of the same throughout the hospitalization. 55-year-old Caucasian male with history of decompensated cirrhosis secondary to chronic hepatitis C infection who presented with left hip pain found to have MRSA bacteremia. He has a history significant for I.V. drug abuse and TEE was needed to rule out infective endocarditis. Upper endoscopy was done to evaluate for esophageal varices prior to his TEE. He was found to have two columns of large esophageal varices with no red wale sign. TEE was then preformed. Given their large size of the varices, immediately post-TEE EGD again performed to evaluate the esophageal mucosa; it showed intact esophageal mucosa and no active bleeding. He underwent uneventful endoscopic variceal ligation (EVL). In the presented cases, TEE was not associated with post-procedural gastrointestinal bleeding. However, given potential for mucosal trauma during TEE in patients with esophageal varices, tandem EGD-TEE is a safe, efficient, time-saving and patient-centered approach to the evaluation and management of esophageal varices pre-and-post TEE respectively.