To TOE or not to TOE? That is the question in patients with portal hypertension and varices

[...]the safety of performing a TOE in such patients is debated by clinicians due to the perceived risk of postprocedural bleeding. 2 Three small studies have analysed post-TOE bleeding complications in patients with varices, having reported no bleeding in 26, 14 and 23 patients. 3-5 We hypothesised that direct external trauma by the echocardiographic probe is unlikely to cause significant bleeding, as variceal bleeding is primarily caused by wall tension, a function of increasing variceal diameter and internal pressure. 6 We therefore audited post-TOE bleeding rates at an Australian liver transplant referral centre in patients who had both varices or portal hypertension and a TOE based on International Classification of Diseases 10 coding from 1995 to 2010. Table 1 % of TOEs (n=30) Number of TOEs Altered antibiotic treatment regimens Reduced regimens by excluding endocarditis 70 21 Prolonged regimens by confirming endocarditis 13.4 4 Total 83.4 25 Altered antiplatelet therapy Aspirin ceased as no cardiac cause for embolisation found 3.4 1 Total 3.4 1 Guided surgical management Confirmed patent foramen ovale which were later closed 6.7 2 Allowed liver transplant by excluding intrapulmonary shunts 3.4 1 Aided the placement of an intraoperative pulmonary artery catheter 3.4 1 Total 13.4 4 Acknowledgement: We thank S Shanaka from RMIT University for his assistance with statistical analysis.