An Unusual Cause of Massive Gastrointestinal Bleeding After Transesophageal Echocardiography

Abstract

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) performed by experienced operators has been reported to have an acceptable risk profile. 1 Spier B.J. Larue S.J. Teelin T.C. et al. Review of complications in a series of patients with known gastroesophageal varices undergoing transesophageal echocardiography. J Am Soc Echocardiogr. 2009; 22: 396-400 Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar In 2 large series, the overall morbidity was between 0.18% and 0.2% with only 1 mortality reported in more than 17,000 patients. 2 Kallmeyer I.J. Collard C.D. Fox J.A. et al. The safety of intraoperative transesophageal echocardiography: A case series of 7200 cardiac surgical patients. Anesth Analg. 2001; 92: 1126-1130 Crossref PubMed Scopus (364) Google Scholar , 3 Daniel W.G. Erbel R. Kasper W. et al. Safety of transesophageal echocardiography A multicenter survey of 10,419 examinations. Circulation. 1991; 83: 817-821 Crossref PubMed Scopus (727) Google Scholar The risk of gastrointestinal (GI) bleeding was small. 2 Kallmeyer I.J. Collard C.D. Fox J.A. et al. The safety of intraoperative transesophageal echocardiography: A case series of 7200 cardiac surgical patients. Anesth Analg. 2001; 92: 1126-1130 Crossref PubMed Scopus (364) Google Scholar Indeed, no difference in the incidence of blood in nasogastric aspirates could be found between cardiac patients who had TEE performed and those who did not. 4 Hulyalkar A.R. Ayd J.D. Low risk of gastroesophageal injury associated with transesophageal echocardiography during cardiac surgery. J Cardiothorac Vasc Anesth. 1993; 7: 175-177 Abstract Full Text PDF PubMed Scopus (28) Google Scholar In this context, Spier et al recently argued in favor of using TEE in the setting of known esophageal varices caused by cirrhosis. 1 Spier B.J. Larue S.J. Teelin T.C. et al. Review of complications in a series of patients with known gastroesophageal varices undergoing transesophageal echocardiography. J Am Soc Echocardiogr. 2009; 22: 396-400 Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Nonetheless, the prospect of using TEE in such high-risk patients, especially those who have been anticoagulated, increases the level of concern in most clinicians. In contrast to TEE's safety record, the authors present a very unusual case of a man with a massive GI bleed after routine TEE, originating from a gastric Dieulafoy lesion. To the authors' knowledge, this is the first such case in the literature.