Variceal Banding. El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy

 
This Sequence displays banding of esophageal varices. Endoscopic variceal ligation, a less invasive procedure than endoscopic sclerotherapy.

Video Endoscopic Sequence 1 of 17.

 This Sequence displays banding of esophageal varices.
 Endoscopic variceal ligation, a less invasive procedure
 than endoscopic sclerotherapy.

 For more endoscopic details, download the video clip
 by clicking on the endoscopic image. Wait to be
 downloaded complete then Press Alt and Enter for full
 screen.
 All endoscopic images shown in this Atlas contain
 video clips. We recommend seeing the video clips in full
 screen mode.

The esophageal varices are seen in retroflexed view. Esophageal varices eventually develop in most patients with cirrhosis, but variceal bleeding occurs in only one third of them. Treatment of patients at highest risk for bleeding is critical because of the high risk of death with each episode of variceal hemorrhage. The goal of treatment of portal hypertension is decreased variceal flow, which is achieved by reducing either portal venous inflow or resistance to portal outflow.

Video Endoscopic Sequence 2 of 17.

 The esophageal varices are seen in retroflexed view.

 Esophageal varices eventually develop in most patients
 with cirrhosis, but variceal bleeding occurs in only one third
 of them. Treatment of patients at highest risk for bleeding
 is critical because of the high risk of death with each
 episode of variceal hemorrhage. The goal of treatment of
 portal hypertension is decreased variceal flow, which is
 achieved by reducing either portal venous inflow or
 resistance to portal outflow.
suction is applied through the endoscope, and the band is released over the entrapped varix . The clear plastic cylinder of the variceal ligation device is seen attached to the end of the endoscope. The portal venous system, formed by the confluence of the superior mesenteric vein and the splenic vein drains the stomach, the large and small intestine, the pancreas, and the spleen. An important feature of this system is that a number of its tributaries also communicate with the systemic circulation. These include the intrinsic and extrinsic veins of the gastroesophageal junction; hemorrhoidal veins of the anal canal; paraumbilical veins and the recanalized falciform ligament; the splenic venous bed and the left renal vein; and the retroperitoneum. In portal hypertension, these venous collaterals dilate and allow portal venous blood to return to the systemic circulation. Clinically, the most significant collaterals are the intrinsic veins of the gastroesophageal junction, which are located close to the mucosal surface. They are the collaterals most likely to bleed when dilated because of increased blood flow.

Video Endoscopic Sequence 3 of 17.

 Suction is applied through the endoscope, and the band is
 released over the entrapped varix.

 The clear plastic cylinder of the variceal ligation device is
 seen attached to the end of the endoscope.

 The portal venous system, formed by the confluence of the
 superior mesenteric vein and the splenic vein drains the
 stomach, the large and small intestine, the pancreas, and
 the spleen. An important feature of this system is that a
 number of its tributaries also communicate with the
 systemic circulation. These include the intrinsic and
 extrinsic veins of the gastroesophageal junction;
 hemorrhoidal veins of the anal canal; paraumbilical veins
 and the recanalized falciform ligament; the splenic venous
 bed and the left renal vein; and the retroperitoneum.
 In portal hypertension, these venous collaterals dilate and
 allow portal venous blood to return to the systemic
 circulation.
 Clinically, the most significant collaterals are the intrinsic
 veins of the gastroesophageal junction, which are located
 close to the mucosal surface. They are the collaterals most
 likely to bleed when dilated because of increased blood
 flow.
More bands have been placed on the varices, resulting in spherical blebs. Note the colored elastic bands strangulating each varix at the base. A typical appearance after a band has been placed at its base. Below the small circular band, which failed to deliver properly is observed.

Video Endoscopic Sequence 4 of 17.

 More bands have been placed on the varices, resulting in
 spherical blebs. Note the colored elastic bands
 strangulating each varix at the base.
 A typical appearance after a band has been placed at its
 base.
 Below the small circular band, which failed to deliver
 properly is observed.

As seen through the banding apparatus attached to the tip of the endoscope. Ligation therapy has been used for years as the treatment of hemorrhoids, and the technique was modified for the treatment of esophageal varices.

Video Endoscopic Sequence 5 of 17.

 As seen through the banding apparatus attached to the tip
 of the endoscope.
 Ligation therapy has been used for years as the treatment
 of hemorrhoids, and the technique was modified for the
 treatment of esophageal varices.
The video clip displays two varices with typical appearance after a band has been placed at its base. Variceal hemorrhage accounts for one third of all deaths related to cirrhosis. To date, many modalities of treating variceal bleeding have been devised, including pharmacological therapy. Treatment of variceal hemorrhage includes resuscitation, initial hemostasis, and prevention of complications and recurrent bleeding. Intravenous vasoactive agents such as terlipressin, somatostatin, octreotide, or vapreotide should be administered in patients with suspected variceal bleeding. Endoscopic treatment remains the mainstay of treatment.

Video Endoscopic Sequence 6 of 17.

 The video clip displays two varices with typical
 appearance after a band has been placed at its base.

 Variceal hemorrhage accounts for one third of all deaths
 related to cirrhosis. To date, many modalities of treating
 variceal bleeding have been devised, including
 pharmacological therapy. Treatment of variceal
 hemorrhage includes resuscitation, initial hemostasis, and
 prevention of complications and recurrent bleeding.
 Intravenous vasoactive agents such as terlipressin,
 somatostatin, octreotide, or vapreotide should be
 administered in patients with suspected variceal bleeding.
 Endoscopic treatment remains the mainstay of treatment.

 
A varix has been ligated at the cardias.

Video Endoscopic Sequence 7 of 17.


        A varix has been ligated at the cardias.

 
Retroflexed view of cardias, the video clip display four varices that have been banding.

Video Endoscopic Sequence 8 of 17.

 Retroflexed view of cardias, the video clip display four
 varices that have been banding.

 
The video clip displays two varices that have been banding. Note the raised mucosal bleb (the varix) with a black band at the base.

Video Endoscopic Sequence 9 of 17.

 The video clip displays two varices that have been banding.
 Note the raised mucosal bleb (the varix) with a black band
 at the base.
 
 
Follow up, 5 days after the banding. An endoscopy was performed to follow up the banding treatment, the four varices were with necrotic appearance. Similar of the treatment for hemorrhoids with banding.

Video Endoscopic Sequence 10 of 17.

           Follow up, 5 days after the banding.

 An endoscopy was performed to follow up the banding
 treatment; the four varices were with necrotic appearance.
 similar of the treatment for hemorrhoids with banding.
 
Another image and video of the follow up some varices are seen with white color due to necrosis exerted by the bands.

Video Endoscopic Sequence 11 of 17.

 Another image and video of the follow up some varices
 are seen with white color due to necrosis exerted by the
 bands. 
Two necrotic varices are appreciated at the cardias.

Video Endoscopic Sequence 12 of 17.

 Two necrotic varices are appreciated at the cardias.

  
Retroflexed image, an ulceration is observed where the band was come off, attach to the endoscope a fibrin fragment is observed which recently has been fallen from this ulceration.

Video Endoscopic Sequence 13 of 17.

 Retroflexed image, an ulceration is observed where the
 band was come off, attach to the endoscope a fibrin
 fragment is observed which recently has been fallen from
 this ulceration.
 

 
A new follow up, after two weeks of the variceal band treatment. Status post treatment was observed, some ulcers where the varices were found. The rubber band has already fallen off, leaving behind an oozing ulcer.

Video Endoscopic Sequence 14 of 17.

 A new follow up after two weeks of the variceal band
 treatment. Status post treatment was observed, some
 ulcers where the varices were found. 
 The rubber band has already fallen off, leaving behind an
 oozing ulcer.

The image and the video show multiple oozing ulcer.

Video Endoscopic Sequence 15 of 17.

 The image and the video show multiple oozing ulcer.
Another post ligation ulcer is observed retroflexed image.

Video Endoscopic Sequence 16 of 17.

 Another post ligation ulcer is observed retroflexed image.
 
 See the video clip.

This image shows the status of variceal banding. The scope is retroflexed in the stomach to check for gastric varices, none are seen. The ulcer is seen at the gastric cardias. Because varices tend to recur over time, surveillance endoscopy must be performed every 6 to 12 months so that banding can be reinstituted as needed. Repeated endoscopic treatment eradicates esophageal varices in most patients, and provided that follow up is adequate serious recurrent variceal bleeding is uncommon. Because the underlying portal hypertension persists, patients remain at risk of developing recurrent varices and therefore require lifelong regular surveillance endoscopy.

Video Endoscopic Sequence 17 of 17.

 This image shows status post variceal banding.
 The scope is retroflexed in the stomach to check for gastric
 varices, none are seen.
 The ulcer is seen at the gastric cardias.
 Because varices tend to recur over time, surveillance
 endoscopy must be performed every 6 to 12 months so that
 banding can be reinstituted as needed.
 Repeated endoscopic treatment eradicates esophageal
 varices in most patients, and provided that follow up is
 adequate serious recurrent variceal bleeding is uncommon.
 Because the underlying portal hypertension persists,
 patients remain at risk of developing recurrent varices and
 therefore require lifelong regular surveillance endoscopy.

Sequences of images and videos of a case on hemorrhage due status post rubber band ligation of esophageal varices. A 77 year-old female, one month previously she started with her first hematemesis, she was hospitalized in a National Hospital called " Hospital Rosales". She was stabilized with intavenous liquid and blood transfusion. The hemorrhage was stopped with the Minnesota balloon. After that, 4 rubber bands were placed in the middle third of the esophagus.

Video Endoscopic Sequence 1 of 25.

 Sequences of images and videos of a case on hemorrhage
 due status post rubber band ligation of esophageal varices.
 A 77 year-old female, one month previously she started with
 her first hematemesis, she was hospitalized in a National
 Hospital called “ Hospital Rosales”. She was stabilized
 with intavenous liquid and blood transfusion.
 The hemorrhage was stopped with the Minnesota balloon.
 After that, 4 rubber bands were placed in the middle third of
 the esophagus. 

SStatus post rubber band ligation of esophageal varices. Some ulcers are observed, one of them with vessel and blood clots. "Stigmata of Bleeding". Ligation therapy has been used for years as treatment of hemorrhoids, and the technique was modified for the treatment of esophageal varices.

Video Endoscopic Sequence 2 of 25.

 Status post rubber band ligation of esophageal varices.

 Some ulcers are observed, one of them with vessel and
 blood clots.
              “Stigmata of Bleeding”.

 Ligation therapy has been used for years as treatment of
 hemorrhoids, and the technique was modified for the
 treatment of esophageal varices.
 
Sclerotherapy Versus Banding for Variceal Bleeding. Endoscopic sclerotherapy also reduces the rate of rebleeding, although overall mortality is not affected. The main disadvantage of endoscopic sclerotherapy is the variable incidence of local and systemic complications, with serious complications occurring in 10-20% of patients, leading to a 2-5% procedure-related mortality. Multiple studies have demonstrated that variceal ligation has a remarkably low complication rate. A number of studies have been completed to compare the efficacy and safety of endoscopic sclerotherapy versus endoscopic variceal ligation. These studies demonstrate that ligation is equally as effective as sclerotherapy in achieving control of acute variceal bleeding. On the basis of the results of a number of trials comparing sclerotherapy with band ligation, endoscopic variceal ligation has evolved to be the preferred first line modality for the endoscopic treatment of esophageal variceal bleeding.

Video Endoscopic Sequence 3 of 25.

 Sclerotherapy Versus Banding for Variceal Bleeding.
 Endoscopic sclerotherapy also reduces the rate of
 rebleeding, although overall mortality is not affected. The
 main disadvantage of endoscopic sclerotherapy is the
 variable incidence of local and systemic complications, with
 serious complications occurring in 10-20% of patients,
 leading to a 2-5% procedure-related mortality. Multiple
 studies have demonstrated that variceal ligation has a
 remarkably low complication rate. A number of
 studies have been completed to compare the efficacy and
 safety of endoscopic sclerotherapy versus endoscopic
 variceal ligation. These studies demonstrate that ligation is
 equally as effective as sclerotherapy in achieving control of
 acute variceal bleeding.
 On the basis of the results of a number of trials comparing
 sclerotherapy with band ligation, endoscopic variceal
 ligation has evolved to be the preferred first line modality
 for the endoscopic treatment of esophageal variceal
 bleeding.
 
Retroflexed view in the esophagus some ulcers are observed to the left side.

Video Endoscopic Sequence 4 of 25.

 Retroflexed view in the esophagus some ulcers are
 observed to the left side.
 

 

Status post Minnesota tube insertion. Necrosis and ulceration are appreciated.

Video Endoscopic Sequence 5 of 25.

 Status post Minnesota tube insertion. Necrosis and
 ulceration are appreciated.
 Retroflexed view of the cardias.          

Frontal view of the cardias. There are some ulceration at this level due to a Minnesota tube.

Video Endoscopic Sequence 6 of 25.

 Frontal view of the cardias. There are some ulceration at
 this level due to a Minnesota tube.
      
Sclerotherapy injection of the bleeding area of the status post rubber band ligation.

Video Endoscopic Sequence 7 of 25.

 Sclerotherapy injection of the bleeding area of the status
 post rubber band ligation.
 Polydocanol 0.75% was used. 
 
Successfully injected, bleeding did not recur. This sclerotherapy proved to be a life-saving procedure.

Video Endoscopic Sequence 8 of 25.

 Successfully injected, bleeding did not recur.
 This sclerotherapy proved to be a life-saving procedure. 
 The patient was discharged from the hospital on the next
 day.
12 days after the first sclerotherapy, we performed a second elective session of variceal injection. The sequences of images and videos display this procedure. We planned to inject four further varices on this day, Note the scar tissue on the right side of the image above due to status post variceal ligation.

            Video Endoscopic Sequence 9 of 25.

 12 days after the first sclerotherapy, we performed a
 second elective session of variceal injection. The
 sequences of images and videos display this procedure.
 We planned to inject four further varices on this day,
 Note the scar tissue on the right side of the image above
 due to status post variceal ligation.
1.5 ml of Polydocanol at 1.5% was injected with a 4.15 minute time delay before the injector was retracted.

Video Endoscopic Sequence 10 of 25.

 1.5 ml of Polydocanol at 1.5% was injected with a 4.15
 minute time delay before the injector was retracted.
The image and video display the retraction caused by the injector as well as a slight hemorrhage which originates in the variceal wall.

Video Endoscopic Sequence 11 of 25.


 The image and video display the retraction caused by the
 injector as well as a slight hemorrhage which originates in
 the variceal wall.

This image and the video show the third sclerotherapy applied on a large vein which presented with various red signs. Variceal appearance on endoscopy (red signs) Red wale marks (longitudinal red streaks on varices) Cherry-red spots (red, discrete, flat spots on varices) Hematocystic spots (red, discrete, raised spots) Diffuse erythema.

Video Endoscopic Sequence 12 of 25.

 This image and the video show the third sclerotherapy
 applied on a large vein which presented with various red
 signs.
 Variceal appearance on endoscopy ("red signs")
 Red wale marks (longitudinal red streaks on varices)
 Cherry-red spots (red, discrete, flat spots on varices)
 Hematocystic spots (red, discrete, raised spots)
 Diffuse erythema.
Maintaining a certain force on the injector during 4 minutes Polydocanol was injected.

Video Endoscopic Sequence 13 of 25.

 Maintaining a certain force on the injector during 4 minutes
 Polydocanol was injected.
The injector is retracted and a small ulcer is observed as a result of the injection.

Video Endoscopic Sequence 14 of 25.

 The injector is retracted and a small ulcer is observed as a
 result of the injection.

The fourth sclerotherapy is displayed in this image and the video.

Video Endoscopic Sequence 15 of 25.

 The fourth sclerotherapy is displayed in this image
 and the video.
  

Some bleeding is observed as a consequence of the sclerotherapy. The bleeding, which originated in the variceal wall, stopped spontaneously.

Video Endoscopic Sequence 16 of 25.

 Some bleeding is observed as a consequence of the
 sclerotherapy. The bleeding, which originated in the
 variceal wall, stopped spontaneously.
In sequence to the images presented above, you can see hemorrhage and blood clots, consequence of the last injection. The endoscopist needs to develop a certain degree of self-confidence.

Video Endoscopic Sequence 17 of 25.

 In sequence to the images presented above, you can see
 hemorrhage and blood clots, consequence of the last
 injection.
 The endoscopist needs to develop a certain degree of
 self-confidence.
This post-procedure control image shows no active bleeding. After a period of observation the procedure was considered complete. The patient was discharged from the hospital the next day.

 Video Endoscopic Sequence 18 of 25.

 This post-procedure control image shows no active
 bleeding. After a period of observation the procedure was
 considered complete. The patient was discharged from the
 hospital the next day.
 The image above displays some degree of hypertensive
 portal gastropathy. 

Two years later the patient re-bleeds, She had not taken a suitable medical control, the cirrhosis has progressed, now with ascitis. The hemoglobin was 6.0 gr/dl.

Video Endoscopic Sequence 19 of 25.

 Two years later the patient re-bleeds, She had not taken
 a suitable medical control, the cirrhosis has progressed,
 now with ascitis. The hemoglobin was 6.0 gr/dl.
The image and the video display bleeding from esophageal varix.

Video Endoscopic Sequence 20 of 25.

 The image and the video display bleeding from esophageal
 varix. 

Many varices are appreciated with red sign.

Video Endoscopic Sequence 21 of 25.

 Many varices are appreciated with “the red sign”.
The exactly site of bleeding was located at the anterior wall of the esophagus near two cm of the gastroesophageal junction.

Video Endoscopic Sequence 22 of 25.

 The exactly site of bleeding was located at the anterior wall
 of the esophagus near two cm of the gastroesophageal
 junction.

Another image and the video of the site of bleed.

Video Endoscopic Sequence 23 of 25.

 Another image and the video of the site of bleed.
We beging with the procedure to banding the varix.

Video Endoscopic Sequence 24 of 25.

 We beging with the procedure to banding the varix.
The bleeding has been stopped, tree varix were ligated. Patient was discharged from the hospital with an appointment to eradicate the varix with the same method

Video Endoscopic Sequence 25 of 25.

 The bleeding has been stopped, tree varix were ligated.
 Patient was discharged from the hospital with an
 appointment to eradicate the varix with the same method.
Banding of Esophageal Varices. Narrow endoscopic view through the rubber band delivery attachment placed on the tip of the endoscope. The variceal banding technique is similar to hemorrhoid banding and involves placing small elastic bands around varices in the distal 5 cm of the esophagus. Varices are suctioned into the banding device and bands are released around the base of the varix by pulling a trip wire via the biopsy channel. The advantages of band ligation over sclerotherapy include fewer local complications (secondary bleeding from ulcers or strictures), no systemic side effects, and the need for fewer treatments for variceal obliteration. Some of the drawbacks of band ligation include a restricted endoscopic view (due to the banding device and blood pooling within the hood mechanism), difficulty-performing treatments in the etroflexed position in the fundus of the stomach.

 Video Endoscopic Sequence 1 of 4.

Banding of Esophageal Varices.

 Narrow endoscopic view through the rubber band delivery
 attachment placed on the tip of the endoscope.
 The variceal banding technique is similar to hemorrhoid
 banding and involves placing small elastic bands around
 varices in the distal 5 cm of the esophagus. Varices are
 suctioned into the banding device and bands are released
 around the base of the varix by pulling a trip wire via the
 biopsy channel. The advantages of band ligation over
 sclerotherapy include fewer local complications (secondary
 bleeding from ulcers or strictures), no systemic side effects,
 and the need for fewer treatments for variceal obliteration.
 Some of the drawbacks of band ligation include a restricted
 endoscopic view (due to the banding device and blood
 pooling within the hood mechanism), difficulty-performing
 treatments in the retroflexed position in the fundus of the
 stomach.
Banding of Esophageal Varices. Two neighboring esophageal varices, which have been successfully banded. Note the improved view through the clear multi-banding apparatus. Note the raised mucosal bleb (the varix) with a black band at the base.

Video Endoscopic Sequence 2 of 4.

Banding of Esophageal Varices.

 Two neighboring esophageal varices, which have been
 successfully banded. Note the improved view through the
 clear multi-banding apparatus. Note the
 raised mucosal bleb (the varix) with a black band at the
 base.

Banding of Esophageal Varices.

Video Endoscopic Sequence 3 of 4.

             Banding of Esophageal Varices.
Banding of Esophageal Varices. Multiple studies have demonstrated that variceal ligation has a remarkably low complication rate. A number of studies have been completed to compare the efficacy and safety of endoscopic sclerotherapy versus endoscopic variceal ligation. These studies demonstrate that ligation is equally as effective as sclerotherapy in achieving control of acute variceal bleeding. rebleeding and mortality are less after variceal ligation. Also, the number of procedures required to achieve obliteration of varices is less with variceal ligation than with sclerotherapy in nearly all comparative studies. Finally, complications, both minor and major, appear to be less with variceal ligation than sclerotherapy.

Video Endoscopic Sequence 4 of 4.

 Multiple studies have demonstrated that variceal ligation
 has a remarkably low complication rate.
 A number of studies have been completed to compare the
 efficacy and safety of endoscopic sclerotherapy versus
 endoscopic variceal ligation. These studies demonstrate
 that ligation is equally as effective as sclerotherapy in
 achieving control of acute variceal bleeding.
 rebleeding and mortality are less after variceal ligation.
 Also, the number of procedures required to achieve
 obliteration of varices is less with variceal ligation than
 with sclerotherapy in nearly all comparative studies.
 Finally, complications, both minor and major, appear to be
 less with variceal ligation than sclerotherapy.
Variceal hemorrhage. A 74 year-old female. Two months previous had her first episode of bledding due to esophageal varices, at that time six varices were ligated, the patient did not returned to her appoinment for a new session of variceal ligation.

Video Endoscopic Sequence 1 of 4.

Variceal hemorrhage.

 A 74 year-old female. Two months previous had her first
 episode of bledding due to esophageal varices, at that
 time six varices were ligated, the patient did not returned
 to her appoinment for a new session of variceal ligation.
 
Another image and video of the site of bled, two scars are observed of the previous treatment. Bleeding from the varices in the region of the gastroesophageal junction is a life threatening medical emergency usuallly occurring in the setting of cirrhosis and portal hypertension. The risk of bleeding is related to the degree of portal hypertension and variceal size. It often occurs without obvious precipitating cause.

Video Endoscopic Sequence 2 of 4.

 Another image and video of the site of bled, two scars
 are observed of the previous treatment.

 Bleeding from the varices in the region of the
 gastroesophageal junction is a life threatening medical
 emergency usually occurring in the setting of cirrhosis and
 portal hypertension. The risk of bleeding is related to the
 degree of portal hypertension and variceal size. It often
 occurs without obvious precipitating cause. The usual
 presentation is massive hematemesis with or without
 melena. However, many patients with varices bleed from
 other lesions such as peptic ulcers or gastritis.

Endoscopic application of rubber band onto the bleeding site. Technique uses a device attached to the tip of the endoscope that allows the varix to be suctioned into a banding chamber, whereupon an elastic band is then deployed around the base of the captured varix. After 3 to 7 days the ligated tissue sloughs, leaving a shallow ulceration with scar tissue.

Video Endoscopic Sequence 3 of 4.

 Endoscopic application of rubber band onto the bleeding
 site.
 Technique uses a device attached to the tip of the
 endoscope that allows the varix to be suctioned into a
 banding chamber, whereupon an elastic band is then
 deployed around the base of the captured varix.
 After 3 to 7 days the ligated tissue sloughs, leaving a
 shallow ulceration with scar tissue.
The varix was successfully ligated. Endoscopic variceal ligation is associated with lower rebleeding rates and a lower frequency of esophageal strictures. Fewer sessions are required to achieve variceal obliteration when compared to sclerotherapy. Endoscopic variceal ligation is considered the endoscopic treatment of choice in the prevention of rebleeding. Sessions are repeated at 7- to 14-day intervals until variceal obliteration (usually 2-4 sessions).

Video Endoscopic Sequence 4 of 4.

The varix was successfully ligated.

 Endoscopic variceal ligation is associated with lower
 rebleeding rates and a lower frequency of esophageal
 strictures. Fewer sessions are required to achieve variceal
 obliteration when compared to sclerotherapy. Endoscopic
 variceal ligation is considered the endoscopic treatment of
 choice in the prevention of rebleeding. Sessions are
 repeated at 7- to 14-day intervals until variceal obliteration
 (usually 2-4 sessions).
 
This endoscopic sequence displays another videos and images of variceal banding some video clips and images are appreciated using a magnifying endoscope. A 56 year-old female, 3 weeks previously was hospitalized due her second upper gastrointestinal bleeding due esophageal varices, a that time we ligated 6 varices. The image and the video shows the statust post ligation.

Video Endoscopic Sequence 1 of 11.

 This endoscopic sequence displays more videos and
 images of variceal banding some video clips and images
 are appreciated using a magnifying endoscope.
 A 56 year-old female, 3 weeks previously was hospitalized
 due her second upper gastrointestinal bleeding due
 esophageal varices, a that time we ligated 6 varices.
 The image and the video shows the status post ligation.
The images and the video clips display some varices that have been ligated and some post ligated ulceration.

Video Endoscopic Sequence 2 of 11.

 The images and the video clips display some varices that
 have been ligated and some post ligated ulceration.
The image displays several scar with fibrin at the cardias The portal venous system, formed by the confluence of the superior mesenteric vein and the splenic vein ( drains the stomach, the large and small intestine, the pancreas, and the spleen. An important feature of this system is that a number of its tributaries also communicate with the systemic circulation. These include the intrinsic and extrinsic veins of the gastroesophageal junction; hemorrhoidal veins of the anal canal; paraumbilical veins and the recanalized falciform ligament; the splenic venous bed and the left renal vein; and the retroperitoneum. In portal hypertension, these venous collaterals dilate and allow portal venous blood to return to the systemic circulation. Clinically, the most significant collaterals are the intrinsic veins of the gastroesophageal junction, which are located close to the mucosal surface. They are the collaterals most likely to bleed when dilated because of increased blood flow.

Video Endoscopic Sequence 3 of 11.

 The image displays several scar with fibrin at the cardias.
 The portal venous system, formed by the confluence of the
 superior mesenteric vein and the splenic vein ( drains the
 stomach, the large and small intestine, the pancreas, and the
 spleen. An important feature of this system is that a number
 of its tributaries also communicate with the systemic
 circulation. These include the intrinsic and extrinsic veins of
 the gastroesophageal junction; hemorrhoidal veins of the
 anal canal; paraumbilical veins and the recanalized falciform
 ligament; the splenic venous bed and the left renal vein; and
 the retroperitoneum.
 In portal hypertension, these venous collaterals dilate and
 allow portal venous blood to return to the systemic
 circulation.
 Clinically, the most significant collaterals are the intrinsic
 veins of the gastroesophageal junction, which are located
 close to the mucosal surface. They are the collaterals most
 likely to bleed when dilated because of increased blood flow.
A esophageal varix that was ligated seen with magnifying.

Video Endoscopic Sequence 4 of 11.

 An esophageal varix that was ligated seen with magnifying.
Another varix appreciated with a magnifying endoscope.

Video Endoscopic Sequence 5 of 11.

 Another varix appreciated with a magnifying endoscope.
The video clip displays some varices that have been ligated as well as several scars with fibrin. (Post ligated status).

Video Endoscopic Sequence 6 of 11.

 The video clip displays some varices that have been ligated
 as well as several scars with fibrin. (Post ligated status).

More images and videos of this endoscopic sequence.

Video Endoscopic Sequence 7 of 11.

 More images and video clips of this endoscopic sequence. 
 Shallow ulcers at the site of each ligation are the rule and
 rarely bleed.

 
The image and the video clip displays one varix that has been ligated as well as a status post banding (3 weeks) retroflexed image.

Video Endoscopic Sequence 8 of 11.

 The image and the video clip displays one varix that has
 been ligated as well as a status post banding (3 weeks)
 retroflexed image.

 
It is essential to identify and treat those patients at highest risk because each episode of variceal hemorrhage carries a 20% to 30% risk of death, and up to 70% of patients who do not receive treatment die within 1 year of the initial bleeding episode.

Video Endoscopic Sequence 9 of 11.

 It is essential to identify and treat those patients at highest
 risk because each episode of variceal hemorrhage carries a
 20% to 30% risk of death, and up to 70% of patients who
 do not receive treatment die within 1 year of the initial
 bleeding episode.

One ulceration post varix ligation is appreciated.

Video Endoscopic Sequence 10 of 11.

 One ulceration post varix ligation is appreciated.
Risk factors for variceal bleeding.

Video Endoscopic Sequence 11 of 11.

 Risk factors for variceal bleeding.

 1. Portal pressure HVPG >12 mm Hg

 2. Varix size and location
 Large esophageal varices
 Isolated cluster of varices in fundus of stomach
 Variceal
 appearance on endoscopy ("red signs")
 Red wale marks (longitudinal red streaks on varices)
 Cherry-red spots (red, discrete, flat spots on varices)
 Hematocystic spots (red, discrete, raised spots)
 Diffuse erythema.          

 3. Degree of liver failure
            Child-Pugh class C cirrhosis
            Presence of ascites
            Tense ascites.

Banding of Esophageal Varices. This endoscopic sequence displays multiple images and video clips concerning the technique of banding of esophageal varices. A 65 year-old female who ten years ago presented ascitis due to Ovarian carcinoma, for which she underwent chemotherapy. Apparently the carcinoma was overcome, and she had been asymptomatic ever since. Ten days previously to the endoscopy, the patient presented ascitis. A CAT scan confirmed the ascitis and micro nodular cirrhosis was detected. We found multiple varices when we performed an upper endoscopy, never had bleeding. Primary prophylaxis: Patients with cirrhosis who have esophageal varices but who have never had a bleeding episode may be treated medically or endoscopically. Without treatment, approximately 30% of cirrhotic patients with varices bleed and this risk is reduced by approximately 50% with therapy.

Video Endoscopic Sequence 1 of 19.

            Banding of Esophageal Varices.

 This endoscopic sequence displays multiple images and
 video clips concerning the technique of banding of
 esophageal varices.
 A 65 year-old female who ten years ago presented ascitis
 due to Ovarian carcinoma, for which she underwent
 chemotherapy.
 Apparently the carcinoma was overcamo, and she had been
 asymptomatic ever since. Ten days previously to the
 endoscopy, the patient presented ascitis. A CAT scan
 confirmed the ascitis and micro nodular
 cirrhosis was detected. We found multiple varices when
 we performed an upper endoscopy, never had bleeding.
 Primary prophylaxis: Patients with cirrhosis who have
 esophageal varices but who have never had a bleeding
 episode may be treated medically or endoscopically.
 Without treatment, approximately 30% of cirrhotic patients
 with varices bleed and this risk is reduced by approximately
 50% with therapy.
Banding of Esophageal Varices. The cardias presents varices; some with the red sign. Studies of endoscopic therapy with ligation (endoscopic banding) demonstrate that in select patients (those with large varices), endoscopic banding may reduce the risk of first bleeding episode when compared with propranolol. Patients with large varices may benefit from a combination of banding with nonselective beta blockers. Secondary prophylaxis: After an initial variceal bleed, the risk of a second bleed is high and therapy is warranted to reduce the risk of rebleeding. The options are similar to those for primary prophylaxis.

Video Endoscopic Sequence 2 of 19.

 The cardias presents varices; some with the red sign.
 Studies of endoscopic therapy with ligation (endoscopic
 banding) demonstrate that in select patients (those with
 large varices), endoscopic banding may reduce the risk of
 first bleeding episode when compared with propranolol.
 Patients with large varices may benefit from a combination
 of banding with nonselective beta blockers. Secondary
 prophylaxis: After an initial variceal bleed, the risk of a
 second bleed is high and therapy is warranted to reduce the
 risk of rebleeding. The options are similar to those for
 primary prophylaxis.
Banding of Esophageal Varices.Cardias in retroflexed view, there are many varices with the red sign, meaning that a possible bleeding was near. The combination of endoscopic therapy with medical therapy is the initial approach to prevent variceal rebleeding. Endoscopic banding is preferred to sclerotherapy because banding is associated with lower bleeding rates and fewer complications.

Video Endoscopic Sequence 3 of 19.

 Cardias in retroflexed view, there are many varices with
 the red sign, meaning that a possible bleeding was near.

 The combination of endoscopic therapy with medical
 therapy is the initial approach to prevent variceal
 rebleeding. Endoscopic banding is preferred to
 sclerotherapy because banding is associated with lower
 bleeding rates and fewer complications.
Banding of Esophageal Varices. Red brillant varices of the cardias are appreciated at the lower portion of the esophagus. The proceeded to do the banding of these varices. It is important to notice that if we do not proceed aggressively when we find this sign, a possible bleeding from this varices may be presented shortly.

Video Endoscopic Sequence 4 of 19.

 Red brillant varices of the cardias are appreciated at the
 lower portion of the esophagus. The proceeded to do the
 banding of these varices. It is important to notice that if we
 do not proceed aggressively when we find this sign, a
 possible bleeding from this varices may be presented
 shortly.

Banding of Esophageal Varices. We can observe in the image and video the technique of banding of varices. We can see how the varix is suctioned and a rubber band is shot at the bottom. The patient complained from chest pain a day later

Video Endoscopic Sequence 5 of 19.

 We can observe in the image and video the technique of
 banding of varices. We can see how the varix is suctioned
 and a rubber band is shot at the bottom. The patient
 complained from chest pain a day later.
Through the banding apparatus several varices can be seen at the cardias.

Video Endoscopic Sequence 6 of 19.

 Through the banding apparatus several varices can be
 seen at the cardias.

Banding of Esophageal Varices. Another example of how the varix is succtioned and a band its placed.

Video Endoscopic Sequence 7 of 19.

 Another example of how the varix is succtioned and a band
 its placed.
Banding of Esophageal Varices. In this image and video we can observe another band placement and other varices already treated at the lower portion of the esophagus.

Video Endoscopic Sequence 8 of 19.

 In this image and video we can observe another band
 placement and other varices already treated at the lower
 portion of the esophagus.
Banding of Esophageal Varices. In the video you can observe the varix already with its band. Other varices with bands can also be seen.

Video Endoscopic Sequence 9 of 19.

 In the video you can observe the varix already with its
 band. Other varices with bands can also be seen.
Banding of Esophageal Varices. You can observe the strangulated varix. Other varices with bands can be seen.

Video Endoscopic Sequence 10 of 19.

 You can observe the strangulated varix. Other varices with
 bands can be seen.
Banding of Esophageal Varices.

Video Endoscopic Sequence 11 of 19.

 More images and video clips
 
 Another image of the sequences that we have been
 discussing.
A follow-up 8 days later. The varices shown signs of necrosis.

Video Endoscopic Sequence 12 of 19.

 A follow-up 8 days later.

The varices shown signs of necrosis.
We demonstrate in this past sequence that banding of esophageal varices is an effective method. Showing minor or no complications, it can be performed as the preferred method for prophylactic or therapeutical management of esophageal varices, especially when bleeding occurs.

Video Endoscopic Sequence 13 of 19.

 We demostrate in this past sequence that banding of
 esophageal varices is an effective method. Showing minor
 or no complications, it can be performed as the preferred
 method for prophylactic or therapeutical management of
 esophageal varices, especially when bleeding occurs.     

Banding of Esophageal Varices. Gastric Cardias, retroflexed image, a necrotic ulceration of the varix is observed.

Video Endoscopic Sequence 14 of 19.

 Gastric Cardias, retroflexed image, a necrotic ulceration of
 the varix is observed.
 
Five months later a new banding of the esophageal varices was performed and 6 varices were ligated. The image and the video clip display some scar of the previous treatment.

Video Endoscopic Sequence 15 of 19.

 Five months later a new banding of the esophageal varices
 was performed and 6 varices were ligated.
 The image and the video clip display some scar of the
 previous treatment.

Some varices of the cardias in retroflexed image.

Video Endoscopic Sequence 16 of 19.

 Some varices of the cardias in retroflexed image.
The video clip displays a long tract of the esophagus displaying multiple varices. The video clip displays a long tract of the esophagus displaying multiple varices.

Video Endoscopic Sequence 17 of 19.

 The video clip displays a long tract of the esophagus
 displaying multiple varices.
Banding of Esophageal Varices. Six varices were ligated at this time.

Video Endoscopic Sequence 18 of 19.

 Six varices were ligated at this time.
Banding of Esophageal Varices. The image and the video display several scars are seen in this area of previous treatment and multiple varices were ligated Repeat banding is performed.

Video Endoscopic Sequence 19 of 19.

 The image and the video display several scars are seen in
 this area of previous treatment and multiple varices were
 ligated.
 Repeat banding is performed.

 
Post variceal ligation hemorrhage This 65 year old female, that had 3 episodes of gastrointestinal bleeding due to esophageal varices. At endoscopy multiple varices with the red spot sign are seen. The red color sign observed by endoscopic examination is a reliable predictive factor for variceal bleeding.

Video Endoscopic Sequence 1 of 17.

 Post variceal ligation hemorrhage

 This 65 year old female that previously had 3 episodes of
 gastrointestinal bleeding due to esophageal varices.
 At endoscopy multiple varices with the red spot sign are
 seen.
 The red color sign observed by endoscopic examination is a
 reliable predictive factor for variceal bleeding.

 
Presence of multiple cherry red spots. Endoscopic signs of esophageal varices and platelet count were significant predictors for the appearance of the red color sign.

Video Endoscopic Sequence 2 of 17.

Presence of multiple cherry red spots.

 Endoscopic signs of esophageal varices and platelet count
 were significant predictors for the appearance of the red
 color sign.

 Variceal appearance on endoscopy ("red signs")

  • Red wale marks (longitudinal red streaks on varices)
  • Cherry-red spots (red, discrete, flat spots on varices)
  • Hematocystic spots (red, discrete, raised spots)
  • Diffuse erythema.
Banding of Esophageal Varices. The varix is aspirated into the banding chamber, and a trip wire dislodges a rubber band carried on the banding chamber, ligating the entrapped varix. One to three bands are applied to each varix, resulting in thrombosis. Band ligation eradicates esophageal varices with fewer treatment sessions and complications than sclerotherapy.

Video Endoscopic Sequence 3 of 17.

Banding of Esophageal Varices.

 The varix is aspirated into the banding chamber, and a trip
 wire dislodges a rubber band carried on the banding
 chamber, ligating the entrapped varix. One to three bands
 are applied to each varix, resulting in thrombosis. Band
 ligation eradicates esophageal varices with fewer
 treatment sessions and complications than sclerotherapy.           

Banding of Esophageal Varices. Endoscopic variceal ligation has evolved to be the preferred first line modality for the endoscopic treatment of esophageal variceal bleeding.

Video Endoscopic Sequence 4 of 17.

Banding of Esophageal Varices.

 Endoscopic variceal ligation has evolved to be the
 preferred first line modality for the endoscopic treatment
 of esophageal variceal bleeding.

 
The varices with with the red spot were ligated.

Video Endoscopic Sequence 5 of 17.

 In this image and the video clip shows that the varices with
 the red spot were ligated.
This picture as well as the video clip display some varices with the red sign that were ligated.

Video Endoscopic Sequence 6 of 17.

This picture as well as the video clip display some varices with the red sign that were ligated.
Endoscopic variceal ligation is safer and more efficacious than sclerotherapy as initial treatment of bleeding esophageal varices, whereas cyanoacrylate injection is the endoscopic treatment of choice for gastric varices. Despite advances in the treatment of variceal bleeding, liver function remains the determining factor of patient survival. Liver transplantation is the only definitive treatment that can alter the course of the disease.

Video Endoscopic Sequence 7 of 17.

 Endoscopic variceal ligation is safer and more efficacious
 than sclerotherapy as initial treatment of bleeding
 esophageal varices, whereas cyanoacrylate injection is the
 endoscopic treatment of choice for gastric varices.

 Despite advances in the treatment of variceal bleeding,
 liver function remains the determining factor of patient
 survival. Liver transplantation is the only definitive
 treatment that can alter the course of the disease.

Video Endoscopic Sequence 8 of 17.

 
Acute Variceal Bleed Six days after the varices were strangulated, patient initiated with hematemesis, an emergency endoscopy was performed. to determine the source of bleeding .

Video Endoscopic Sequence 9 of 17.

 Acute Variceal Bleed

 Six days after the varices were strangulated, patient
 initiated with hematemesis, an emergency endoscopy was
 performed to determine the source of bleeding.
There are two possible sites of the bleeding of two varices that were previously ligated, hemostatic maneuver has been applied with APC.

Video Endoscopic Sequence 10 of 17.

 There are two possible sites of the bleeding two varices
 that were previously ligated, hemostatic maneuver
 has been applied with APC.         
There are a varix with a blood clot in front of the previous one, give us the suspicion of being another site of bled.

Video Endoscopic Sequence 11 of 17.

 There are a varix with a blood clot in front of the previous
 one, give us the suspicion of being another site of bled.

Video Endoscopic Sequence 12 of 17.

 
More hemostatic maneuver with APC.

Video Endoscopic Sequence 13 of 17.

More hemostatic maneuver with APC.
The light produced by the APC is observed.

Video Endoscopic Sequence 14 of 17.

 The light produced by the APC is observed.

 
Endoscopic ligation of esophageal varices combined with APC is superior to ligation alone. Since APC is theoretically well suited for mucosal fibrosis therapy, it can be used for the complete elimination of esophageal varices and for fibrosis of the distal esophageal mucosa.

Video Endoscopic Sequence 15 of 17.

 Endoscopic ligation of esophageal varices combined with
 APC is superior to ligation alone. Since APC is
 theoretically well suited for mucosal fibrosis therapy, it can
 be used for the complete elimination of esophageal varices
 and for fibrosis of the distal esophageal mucosa.
 

 
The site of the bleeding was re- ligated with rubber bands in spite of previous ligated, six day ago. The hemorrhage was stopped.

Video Endoscopic Sequence 16 of 17.

 The site of the bleeding was re- ligated with rubber bands
 in spite of previous ligated, six day ago. The hemorrhage
 was stopped.

 
This image and the video clips show the status post hemostatic maneuvers that have been performed.

Video Endoscopic Sequence 17 of 17.

 This image and the video clips show the status post
 hemostatic maneuvers that have been performed. 

 
This 33 year-old male with alcoholic cirrhosis since two years previously underwent rubber bands due to multiple variceal bleeding carrying out three treatments with rubber bands.This one is the fourth episode, this morning started with two episodes of melena, in spite of his disease the patient has continued with his alcoholism. Endoscopy was performed under conscious sedation.

Video Endoscopic Sequence 1 of 10.

Fibrosis due to a Status post banding and variceal hemorrhage due to a varix of the esophagus

 This 33 year-old male with alcoholic cirrhosis since two
 years previously underwent rubber bands due to multiple
 variceal bleeding carrying out three treatments with rubber
 bands. This one is the fourth episode, this morning started
 with two episodes of melena, in spite of his disease the
 patient has continued with his alcoholism. Endoscopy was
 performed under conscious sedation.

 
We can see an esophageal varix with a white point (ulcer). The probable bleeding point has been identified, with extensive fibrosis in the surrounding area because of previous banding sessions.

Video Endoscopic Sequence 2 of 10.

 We can see an esophageal varix with a white point (ulcer).
 The probable bleeding point has been identified, with
 extensive fibrosis in the surrounding area because of
 previous banding sessions.

 
More image and video clip of the varix and it ulceration

Video Endoscopic Sequence 3 of 10.

More image and video clip of the varix and it ulceration

 The mucosa and submucosa of the esophagus (containing
 the variceal channels) are ensnared, leading to
 strangulation, sloughing, and eventual fibrosis—ideally
 with obliteration of the varices.

 
StdCarlvarix4

Video Endoscopic Sequence 4 of 10.

 The banding treatment has been initiated, due to the fibrosis near of the varix, we have some experience that the band can be slid

 

Video Endoscopic Sequence 5 of 10.

 Jet of blood from an esophageal varix

After several attempts to suck, bleeding is activated but we continued trying to suck until finally sufficient tissue of varix is sucked and two bands go off.
 

 
StdCarlvarix6

Video Endoscopic Sequence 6 of 10.

 

Important advances have been made in the management of variceal bleeding. Despite these advances, bleeding in the patient with cirrhosis remains one of the most demanding clinical challenges that a gastroenterologist may face

 
Hemostasis achieved in bleeding varix by the endoscopic application of rubber bands onto the bleeding site. Hemostasis achieved in bleeding varix by the endoscopic application of rubber bands onto the bleeding site two bands were deployed .

Video Endoscopic Sequence 7 of 10.

 Hemostasis achieved in bleeding varix by the endoscopic
 application of rubber bands onto the bleeding site two
 bands were deployed.

 
Esophageal varix which have been successfully banded.

Video Endoscopic Sequence 8 of 10.

Esophageal varix which have been successfully banded.

 

Video Endoscopic Sequence 9 of 10.

One band falls, observing the ulcer in the tip of the varix

 
Due to the considerable amount of fibrous tissue surrounding the vessel, in spite of successful banding of the blood vessel, sclerotherapy was administered in the three upper paravariceal cuadrants, to prevent the band from slipping.

Video Endoscopic Sequence 10 of 10.

 Due to the considerable amount of fibrous tissue
 surrounding the vessel, in spite of successful banding of the
 blood vessel, sclerotherapy was administered in the three
 upper paravariceal cuadrants, to prevent the band from
 slipping.