Esophageal Varix
Endoscopic Image of bleeding of Esophageal Varix

Video Endoscopic Sequence 1 of 15.

Endoscopic Image of bleeding of Esophageal Varix

This 65 year-old, diabetic lady, 3 days previously has been hospitalized in another institution because of her first upper GI bleeding manifesting with hematemesis and melena an upper endoscopy displays esophageal varices; patient was discharged from the hospital without specific therapeutical treatment. She was referred to us to evaluate this condition The patient was continued with intermittent episodes of melena. A procedure of banding was planning, at endoscopy a varix with an ulcer in the tip was found (the white nipple sign). The site of bleeding was identified.

White ball appearance was a characteristic finding that appeared after ligation of a varix at the site of bleeding. This finding may be useful in the confirmation of successful ligation of a varix at its bleeding site. (Gastrointest Endosc 1998;47:254-6.).

Endoscopic Image of bleeding of Esophageal Varix

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.


Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Video Endoscopic Sequence 2 of 15.

Two angiectasias were found at the gastric body.

Bleeding esophageal varices is the most serious complication of the portal hypertension, and the greater cause of dead (25% of the patients). The survival after esophageal varices bleeding depends in wide part from the swiftness and effectiveness of hemostasis and from the degree of functional liver reserve.

Endoscopic variceal ligation (EVL) was developed in an effort to find an effective means of treating esophageal varices endoscopically with fewer complications than endoscopic sclerotherapy (ES). The concept was based upon many years of experience treating hemorrhoids with rubber band ligation in patients with and without portal hypertension. EVL works by capturing all or part of a varix resulting in occlusion from thrombosis. The tissue then necroses and sloughs off in a few days to weeks, leaving a superficial mucosal ulceration, which rapidly heals. EVL avoids the use of sclerosant and thus eliminates the deep damage to the esophageal wall that occurs after ES. Collateral vessels near the cardia decrease after EVL and EVL may promote the development of deep gastric collaterals. These factors may also contribute to the effectiveness of EVL for preventing further variceal bleeding . Another interesting finding is that during acute variceal bleeding, the hepatic venous pressure gradient (which correlates with the risk of variceal bleeding) increases after ES, but not after EVL.

 

Endoscopic Image of bleeding of Esophageal Varix

Video Endoscopic Sequence 3 of 15.

Endoscopic Image of bleeding of Esophageal Varix.

At the at the time of being exploring the stomach, the patient present a cough reflex, causing rebleeding of the varix.

The white nipple sign correlated positively with severity of bleeding (patients required more blood transfusion), hematemesis, and signs of shock. Patients with the white nipple sign also tended to undergo emergency endoscopy and have active bleeding at the time of endoscopy. There was no correlation between rebleeding rate after endoscopic therapy and presence of the white nipple sign.

The first patient was treated with EVL in 1986. Since then, advances in the technique have led to its routine use in the care of patients with esophageal varices. One of the biggest advances was the development of the multiple band ligator (Saeed Six-Shooter and Speedbander), which has simplified and improved the safety of EVL.


Endoscopic View of Spurting Esophageal Varix.

Video Endoscopic Sequence 4 of 15.

Endoscopic View of Spurting Esophageal Varix.

Mortality due to variceal bleeding secondary to portal hypertension has decreased significantly in the past 2 decades. Endoscopic therapy has been the mainstay of treatment for acute variceal bleeding. Variceal banding ligation has superceded injection sclerotherapy as the most popular treatment modality for acute bleeding. Multiple banding ligators are widely used with high success in restoring hemostasis. The combination of banding and sclerotherapy may be useful in preventing the early recurrence of varices and rebleeding after initial obliteration of varices. Selective vasoactive agents such as somatostatin analogs also improve the outcome of patients.




Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Video Endoscopic Sequence 5 of 15.

Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Immediately; a therapeutically approach was carry out with banding to the bleeding varix.

Endoscopic variceal ligating devices are placed on the tip of standard endoscopes. The device has a soft sheath potion that fits over the tip of the endoscope and a hard plastic portion. Bands are stretched over the hard portion at the distal end of the device and later deployed onto the varices. Currently available devices are designed for standard and therapeutic sized endoscopes.

The procedure begins after a thorough upper endoscopy to identify the esophageal varices that are to be treated. Actively bleeding varices or those with stigmata indicating recent bleeding (such as a fibrin plug or a "red wale" sign) should be primary targets even if they are not located at the gastroesophageal junction. There are no absolute restrictions on coagulation parameters that preclude performing EVL, although in patients with active bleeding, attempts should be made to improve the coagulation status.

 

Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Video Endoscopic Sequence 6 of 15.

Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Two rubber bands were applied to the bleeding varix.

Endoscopic variceal ligation (EVL) was developed in an effort to find an effective means of treating esophageal varices endoscopically with fewer complications than sclerotherapy.

The concept was based upon many years of experience treating hemorrhoids with rubber band ligation in patients with and without portal hypertension.

Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Video Endoscopic Sequence 7 of 15.

Endoscopic rubber band ligation in treatment of esophageal varices bleeding.

More varices were ligated.

The first patient was treated with EVL in 1986. Since then, advances in the technique have led to its routine use in the care of patients with esophageal varices. One of the biggest advances was the development of the multiple band ligator, which has simplified and improved the safety of EVL.

Rubber Band Ligation

Video Endoscopic Sequence 8 of 15.

Endoscopic rubber band ligation in treatment of esophageal varices bleeding.

EVL works by capturing all or part of a varix resulting in occlusion from thrombosis. The tissue then necroses and sloughs off in a few days to weeks, leaving a superficial mucosal ulceration, which rapidly heals. EVL avoids the use of sclerosant and thus eliminates the deep damage to the esophageal wall that occurs after ES. Collateral vessels near the cardia decrease after EVL, which may be another reason that EVL is effective for preventing further variceal bleeding.


Rubber Band Ligation

Video Endoscopic Sequence 9 of 15.

Endoscopic Image of ligation of Esophageal.

Varices.Another interesting finding is that during acute variceal bleeding the hepatic venous pressure gradient (which correlates with the risk of variceal bleeding) increases after ES, but not after EVL

To date, no single method applicable to all patients with bleeding esophageal varices, but endoscopic rubber band ligation is currently considered the first-line treatment of proper multidisciplinary approach to the patient, both during the acute event than prevention of rebleeding, because it is an effective, safe and repeatable, in experienced hands.

Patient with Cirrhosis of the liver with Ascites.

Video Endoscopic Sequence 10 of 15.

Patient with Cirrhosis of the liver with Ascites.

Two years after, the patient present with severe ascites

The mechanism by which ascites develops in cirrhosis is multifactorial Severe sinusoidal portal hypertension and hepatic insufficiency are the initial factors. They lead to a circulatory dysfunction characterized by arterial vasodilation, arterial hypotension, high cardiac output and hypervolemia and to renal sodium and water retention

.

Click on the image to enlarge in a new windows

Cirrhosis of the liver with Ascites.

Video Endoscopic Sequence 11 of 15.

Cirrhosis of the liver with Ascites.

There are evidences that arterial vasodilation in cirrhosis occurs in the splanchnic circulation and is related to anincreased synthesis of local vasodilators. Vascular resistance is normal or increased in the remaining major vascular territories (kidney, muscle and skin and brain). Splanchnic arterial vasodilation not only impairs systemic hemodynamics and renal function but also alters hemodynamics in the splanchnic microcirculation.

 

 

 




Patient with Cirrhosis of the liver with Ascites.

Video Endoscopic Sequence 12 of 15.

Cirrhosis of the liver with Ascites.

The rapid and high inflow of arterial blood into the splanchnic microcirculation is the main factor increasing hydrostatic pressure in the splanchnic capillaries leading to an excessive production of splanchnic lymph over lymphatic return. Lymph leakage from the liver and other splanchnic organs is the mechanism of fluid accumulation in the abdominal cavity. Continuous renal sodium and water retention perpetuates ascites formation. Large volume paracentesis associated with albumin infusion is the treatment of choice of tense ascites because it is very effective and rapid and is associated with fewer complications that the traditional treatment (sodium restrictionand diuretics).

Ascites

Video Endoscopic Sequence 13 of 15.

Umbilical Hernia with Ascites.

Umbilical hernia is a common finding in cirrhotic patients with ascites. Spontaneous disruption of the hernia and attendant discharge of ascitic fluid is an unusual and rarely reported complication in these patients and is associated with an overall mortality rate of nearly 30%

 

 



 

Patient with Cirrhosis of the liver with Ascites.

Video Endoscopic Sequence 14 of 15.

Cirrhosis of the liver with Ascites.

Pathogenesis of ascites in cirrhosis.
Renal function abnormalities.
Sodium Retention.

The impairment in the renal ability to excrete sodium is the earliest renal dysfunction in cirrhosis. Before the development of ascites, when patients are still compensated (compensated cirrhosis is a term commonly used to define patients prior to the development of any of the major complications of the disease: i.e. ascites, hemorrhage or hepatic encephalopathy), they present subtle abnormalities in renal sodium metabolism. For example they may not escape to the sodium retaining effect of mineralcorticoids or may be unable to excrete a sodium overload. However, as the disease progresses, patients became unable to excrete their regular sodium intake and develop sodium retention.



Click on the image to enlarge in a new windows

 

Patient with Cirrhosis of the liver with Ascites.

Video Endoscopic Sequence 15 of 15.

Cirrhosis of the liver with Ascites.

Water Retention

The kidney is continuously generating free water in the ascending limb of the loop of Hente by a mechanism consisting in an active reabsorption of sodium chloride without a concomitant reabsorption of water. The final volume free water excretion, therefore, depends on theamount of free water reabsorbed in the more distal segments of the nephron, the convoluted distal tubule and the collecting tubule. This process is mediated by antidiuretic hormone (ADH). When ADH is completely inhibited, for example following a water load of 20 mL/kg of body weigh, the distal nephron is almost completely impermeable to water, leading to the excretion of a high urine volume (10 mL/min or more) with low urine osmolality.





Esophageal Varix

Video Endoscopic Sequence 1 of 10.

Acute gastrointestinal bleeding due to a esophageal varix

This a 57-year-old male, internist physician with a history of being a diabetic and having had a treatment for nail fungus, previous 7 years in upper endoscopy, is suspected of varices of the esophagus and 6 years prior in a colonoscopy a peculiar image of a fairly long varix of the colon, see chapter of varices of the rectum. He presented several hematemesis, was hospitalized and was hemodynamically stabilized.

Underwent endoscopy and found varices of the esophagus with active bleeding (fresh blood in the esophagus).

Esophageal Varices

Video Endoscopic Sequence 2 of 10.

Gastroesophageal junction

In search of the exact site of bleeding, the video clip shows the stomach and the gastric cardia, there are sub-cardiac varices.

 

esophagus varices

Video Endoscopic Sequence 3 of 10.

A retroflection maneuver is performed


esophagus varices

Video Endoscopic Sequence 4 of 10.

Gastric cardias shows subcardic varices, retroflexed image.



esophagus varices

Video Endoscopic Sequence 5 of 10.

Exact Site of Bleeding

The exact site of bleeding is observed in one of the varices of the gastroesophageal junction, it is seen torn, above this tear there is a white part corresponding to the light reflection.


 

esophagus varices

Video Endoscopic Sequence 6 of 10.

Two bleeding bands are applied to the Exact Site

Therapeutic endoscopy with band placement begins. In the image and in the video clip, the ulcerated varice is observed, which is being suctioned with the ligation apparatus.

The rupture of gastric varices results in variceal hemorrhage, which is one the most lethal complications of cirrhosis. Endoscopic therapies for varices aim to reduce variceal wall tension by obliteration of the varix. The two principal methods available for esophageal varices are endoscopic sclerotherapy (EST) and band ligation (EBL). The advantages of EST are that it is cheap and easy to use, and the injection catheter fits through the working channel of a diagnostic gastroscope. Endoscopic variceal ligation obliterates varices by causing mechanical strangulation with rubber bands. The following review aims to describe the utility of EBL and EST in different situations, such as acute bleeding, primary and secondary prophylaxis.

 

 

esophagus varices

Video Endoscopic Sequence 7 of 10.

The varice is observed with its tear which has been ligated

 

esophagus varices

Video Endoscopic Sequence 8 of 10.

To the varice of the pair two other bands are applied

 

esophagus varices

Video Endoscopic Sequence 9 of 10.

It proceed with more band therapy.

More bands were applied to several varices in total were ligated four varices.

Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Video Endoscopic Sequence 10 of 10.

Final status of therapeutic treatment



Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Video Endoscopic Sequence 1 of 10.

Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Upper GI bleeding due to Esophageal Varices.
This 42 year-old male, was admitted for massive hematemesis resulted in hypotension, history of alcoholic abuse, after promptly resuscitate and restore circulating blood volume of patient an emergency upper gastrointestinal endoscopy was performed on the first hospital day, It was carried out in the operation room with Endotracheal intubation under general anesthesia.

Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Video Endoscopic Sequence 2 of 10.

Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Mandates aggressive lavage and thorough endoscopy of the stomach to include a retroflexed view of the cardiac portion of the stomach, fresh blood at the gastric fundus is observed.

Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Video Endoscopic Sequence 3 of 10.

Endoscopic rubber band ligation in treatment of esophageal varices bleeding

A yellowish fibrin plug is visible in the 1 o'clock varix indicating the site of recent bleeding.

The exact site of the bleeding has been identify in the Gi Junction, white point of above.


Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Video Endoscopic Sequence 4 of 10.

Endoscopic rubber band ligation in treatment of esophageal varices bleeding

More images and video clips of the exact site of the bleeding. Close-up view of the fibrin plug.



Endoscopic ligation of esophageal varices

Video Endoscopic Sequence 5 of 10.

By retrofletion the gastric cardia is inspected observing the exact site of the bleeding.

One of the most ominous complications of portal hypertension is hemorrhage from esophageal or gastric varices. Patients who bleed from varices have a poor long-term prognosis, irrespective of treatment and few survive more than 5 years. In view of the prognosis of portal hypertensive bleeding, it is clear that poorurgent treatment of acute variceal bleeding and interval management to prevent rebleeding is essential.

Endoscopic ligation of esophageal varices

Video Endoscopic Sequence 6 of 10.

Endoscopic ligation of esophageal varices requires placement of an opaque cylinder over the end of the endoscope.
The exact site of the hemorrhage is ligated.

Variceal bleeding is one of the complications of cirrhosis that leads to significant morbidity and mortality. It is recommended that all patients with cirrhosis be screened for gastroesophageal varices and those with large varices should be offered primary prophylaxis. Nonselective beta-blockers (nadolol or propranolol) are the treatment of choice for primary prophylaxis but there are a number of limitations to their use. A number of studies have evaluated the efficacy of variceal band ligation (VBL) in providing primary prophylaxis, either in comparison to no treatment or to beta-blockers. VBL is very effective in preventing the initial bleed when compared to no treatment, but it is not superior to beta-blockers. In this issue of the journal the effect of beta-blockers on bleeding in patients undergoing VBL is examined and no benefit compared to VBL alone is shown. Thus, patients with large varices should be treated with beta-blockers and VBL should be offered to those cirrhotics who are unable to take beta-blockers. Further study is required to determine if VBL in combination with beta-blockers is more effective than the beta-blockers alone.

 

 

 

Two rubber band have been applied at the site of the bleeding.

Video Endoscopic Sequence 7 of 10.

Two rubber band have been applied at the site of the bleeding.

Endoscopic ligation of esophageal varices

Video Endoscopic Sequence 8 of 10.

The gastric cardias at the retroflexed, observing the varix with beginnings of necrosis.

Endoscopic ligation of esophageal varices

Video Endoscopic Sequence 9 of 10.

More bands were applied to several varices.

Rubber Bands Ligation

Video Endoscopic Sequence 10 of 10.


More varices have been ligated.

 


Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Video Endoscopic Sequence 1 of 26.

This 68 year old man, has a history of long standing alcohol abuse, had two episodes of gastrointestinal bleeding. Multiple red spot are seen.

One of the most ominous complications of portal hypertension is hemorrhage from esophageal or gastric varices. Patients who bleed from varices have a poor long -term prognosis, irrespective of treatment and few survive more than 5 years.







 


 


Endoscopic Ultrasound in Esophagogastric Varices

Video Endoscopic Sequence 2 of 26.

Endoscopic Ultrasound in Esophagogastric Varices

The intraluminal varices are being compressed by the water-filled ballon, and are hardly visible on the endosonographic image. Varices are identified as multiple, well-circumscribed, hypoechoic or anechoic structures that have a tubular or serpiginous appearance; they are located in the submucosal layer.


 


Radial Endosonography. Endoluminal US demonstrated the varices as anechoic areas with communications in the submucosal,  periesophageal, and perigastric regions.

Video Endoscopic Sequence 3 of 26.

Radial Endosonography.

Endoluminal US demonstrated the varices as anechoic
areas with communications in the submucosal,
periesophageal, and perigastric regions.

 


Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Video Endoscopic Sequence 4 of 26.

Endoscopic rubber band ligation in treatment of esophageal varices bleeding

Fitted with a suction cap adapter and passed back down to the level of the GE junction. The varix with the red spot at the GE junction is identified, then gently sucked up into the cap and the band deployed around the varix. A second site just proximal to the first is next selected and this is banded. This process is continued until all the bands are deployed.

In view of the prognosis of portal hypertensive bleeding, it is clear that poorurgent treatment of acute variceal bleeding and interval management to prevent rebleeding is essential. 




 

 


The video clip and the image display one varix is banding. The varix is suctioned into the banding apparatus. The role of endoscopic band ligation in secondary prophylaxis is now indisputable, especially in comparison with sclerotherapy. In the primary prevention of variceal bleeding, band ligation is beginning to have a competitive edge over pharmacological therapy.

Video Endoscopic Sequence 5 of 26.

Endoscopic rubber band ligation in treatment of esophageal varices bleeding

The video clip and the image display one varix is banding.
The varix is suctioned into the banding apparatus.

The role of endoscopic band ligation in secondary
prophylaxis is now indisputable, especially in comparison
with sclerotherapy. In the primary prevention of variceal
bleeding, band ligation is beginning to have a competitive
edge over pharmacological therapy.




Nine varices were ligated in this session.     Long term results comparing band ligation to sclerotherapy reveal that banding requires less number of sessions for active eradication of varices.

Video Endoscopic Sequence 6 of 26.

Nine varices were ligated in this session.

Long term results comparing band ligation to sclerotherapy reveal that banding requires less number of sessions for active eradication of varices.


The video displays multiple varices that have been banding.    The technique is an adaptation of that applied to banding ligation of internal hemorrhoids.

Video Endoscopic Sequence 7 of 26.

The video displays multiple varices that have been banding.

The technique is an adaptation of that applied to banding
ligation of internal hemorrhoids.

 


Magnifying view.  Magnifying view. A large varix was ligated as is seen with magnifying endoscope.

Video Endoscopic Sequence 8 of 26.

Magnifying view.

A large varix was ligated as is seen with magnifying
endoscope.

 


Esophagus Varices

Video Endoscopic Sequence 9 of 26.

The portal vein carries approximately 1500 mL/min of blood from the small and large bowel, the spleen, and the stomach to the liver. Obstruction of portal venous flow, whatever the etiology, results in a rise in portal venous pressure.

The response to increased venous pressure is the development of a collateral circulation diverting the obstructed blood flow to the systemic veins. These portosystemic collaterals form by the opening and dilatation of preexisting vascular channels connecting the portal venous system and the superior and inferior vena cava. High portal pressure is the main cause of
the development of portosystemic collaterals; however, other factors such as active angiogenesis also may be involved. The most important portosystemic anastomoses are the gastroesophageal collaterals. Draining into the azygos vein, these collaterals include esophageal varices, which are responsible for the main complication of portal
hypertension and massive upper GI hemorrhage.

 


Status post rubber band ligation , One week after the banding a new endoscopy was performed. There are multiple fresh scars. 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.One week after the banding a new endoscopy was performed.   One week after the banding a new endoscopy was performed. There are multiple fresh scars. 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 10 of 26.

Status post rubber band ligation

One week after the banding a new endoscopy was performed.

There are multiple fresh scars.
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.





More images and video clips of Status post rubber band ligation.   Shallow ulcers at the site of each ligation are the rule and rarely bleed.

Video Endoscopic Sequence 11 of 26.

Shallow ulcers at the site of each ligation are the rule and
rarely bleed.


Chromoendoscopy using Lugol's solution. Chromoendoscopy involves the application of vital dyes that enhance the visibility of dysplastic mucosa. Vital dyes that have been studied include those that preferentially stain normal squamous mucosa (such as Lugol's iodine).

Video Endoscopic Sequence 12 of 26.

Chromoendoscopy using Lugol's solution.

Chromoendoscopy involves the application of vital dyes that enhance the visibility of dysplastic mucosa. Vital dyes that have been studied include those that preferentially stain normal squamous mucosa (such as Lugol's iodine).



One ulceration post varix ligation is appreciated (normal  status).

Video Endoscopic Sequence 13 of 26.

One ulceration post varix ligation is appreciated (normal status).


Rubber banding status.

Video Endoscopic Sequence 14 of 26.

More images and video clip of post banding status.



A follow up Endoscopy after one month. Status post banding, Multiple scars are seen. Banding ligation sessions are repeated at 7- to 14-day intervals until obliteration of varices is achieved. Eradication of varices usually requires two to four band ligation sessions.                                                                                                                                                                                                                                                                                                                                                                              ng multiple scars are seen.

Video Endoscopic Sequence 15 of 26.

A follow up Endoscopy after one month.

Status post banding.

Multiple scars are seen.

Banding ligation sessions are repeated at 7 to 14-day intervals until obliteration of varices is achieved. Eradication of varices usually requires two to four band ligation sessions.

 

 


Multiple scars are seen in this image as well as the video clip.

Video Endoscopic Sequence 16 of 26.

Multiple scars are seen in this image as well as the video clip.


A retroflexed view of the esophagus is observed, the multiple scars of the status post banding are seen.

Video Endoscopic Sequence 17 of 26.

A retroflexed view of the esophagus is observed, the multiple scars of the status post banding are seen.



Spurting esophageal varix. Due to the retroflexed maneuver, the tip of the endoscope touched causing this bleeding that was resolved easily with argon plasma coagulator

Video Endoscopic Sequence 18 of 26.

Spurting esophageal varix.

Due to the retroflexed maneuver, the tip of the endoscope
touched causing this bleeding that was resolved easily with
argon plasma coagulator.



 


In the video clip, you can see a bleeding from a small fissure at the gastroesophageal junction.

Video Endoscopic Sequence 19 of 26.

In the video clip, you can see a bleeding from a small
fissure at the gastroesophageal junction.


In this image and the video clip, the catheter of the argon plasma coagulator is observed that will initiate the therapeutical approach. Endoscopic variceal ligation is an established procedure for eradication of esophageal varices. However, varices frequently recur after endoscopic variceal ligation. Argon plasma coagulation has been used as supplemental treatment for eradication of varices and for prevention of variceal recurrence.

Video Endoscopic Sequence 20 of 26.

In this image and the video clip, the Probe of the argon
plasma coagulator is observed that will initiate the
therapeutical approach.

Endoscopic variceal ligation is an established procedure
for eradication of esophageal varices. However, varices
frequently recur after endoscopic variceal ligation. Argon
plasma coagulation has been used as supplemental
treatment for eradication of varices and for prevention of
variceal recurrence.


 


To overcome this bleeding the argon plasma coagulator  was used. 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 21 of 26.

To overcome this bleeding the argon plasma coagulator
was used.
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 bleeding was overcome easily with this therapeutical resource.  Use of argon plasma coagulation (APC) to promote mucosal fibrosis has been described in some clinical setting.

Video Endoscopic Sequence 22 of 26.

The bleeding was overcome easily with this therapeutical resource.

Use of argon plasma coagulation (APC) to promote mucosal fibrosis has been described in some clinical setting.

Argon Plasma Coagulator is a new device that allows for non-contact monopolar coagulation of bleeding surfaces, and devitalization of tissue in the gastrointestinal tract. It is safer and much less expensive than lasers, more effective than bipolar cauterization techniques.




One month after the previous images.   Six varices were ligated in this session of therapy.

Video Endoscopic Sequence 23 of 26.

One month after the previous images.

Six varices were ligated in this session of therapy.

 


Some fundic varices are observed.

Video Endoscopic Sequence 24 of 26.

Some fundic varices are observed.


Some varices are banding  above of the multiple scars.

Video Endoscopic Sequence 25 of 26.

Some varices are banding above of the multiple scars.

 


There are some ligated varices at the mid esophagus.   The evolution of the patient has been satisfactory to date.

Video Endoscopic Sequence 26 of 26.

There are some ligated varices at the mid esophagus.
The evolution of the patient has been satisfactory to date.


esophageal variceal bleeding

Video Endoscopic Sequence 1 of 6.

42 year- old male, 15 days ago, had been hospitalized for esophageal variceal bleeding was referred to our endoscopic unit for specific treatment placing six bands.

 

 

chains of varices,

Video Endoscopic Sequence 2 of 6.

Note the chains of varices, retroflexed maneuver into the esophagus.

Esophageal varices

Video Endoscopic Sequence 3 of 6.

Within the gastroesophageal junction are seen several varices with the red sign.

Endoscopic variceal ligation

Video Endoscopic Sequence 4 of 6.

Therapy is initiated with bands.

Endoscopic variceal ligation is based on the widely used technique of rubber-band ligation of hemorrhoids. The esophageal mucosa and the submucosa containing varices are ensnared, causing subsequent strangulation, sloughing, and eventual fibrosis, resulting in obliteration of the varices Rebleeding occurs less frequently with endoscopic varicea ligation (26%) than with endoscopic sclerotherapy (45%).

 

Endoscopic variceal ligation

Video Endoscopic Sequence 5 of 6.

Endoscopic variceal ligation

In this video clip can observe the placement of some bands.

Endoscopic ligation requires placement of an opaque cylinder over the end of the endoscope. This decreases the endoscopic field of view and may allow pooling of blood. Thus, in patients with active bleeding, visualization may be impaired more with ligation than with sclerotherapy.

Endoscopic variceal ligation

Video Endoscopic Sequence 6 of 6.

Endoscopic variceal ligation

In total there were six varices that were ligated a new session will be programmed shortly.

Thrombocytopenia, presence of encephalopathy, low hemoglobin on admission, and endoscopic findings large varices, presence of red color sign, fundal varix and portal gastropathy are predictors of esophageal variceal bleeding. This stratification may help clinicians identify cirrhotic patients who will need aggressive pharmacologic and endoscopic intervention for variceal bleeding.

Endoscopic variceal ligation

Video Endoscopic Sequence 1 of 15.

Severe bleeding of the upper digestive system after two days of band ligation.

This 57 year-old male with chronic alcoholism and cirrhosis of the liver with esophageal varices, had been previously hospitalized in two occasions due to a severe upper gastrointestinal bleeding. He did not received specific treatment for these varices, so he was referred to a specific therapeutic procedure.

Endoscopic variceal ligation

Video Endoscopic Sequence 2 of 15.

In this first session six varices were ligated.

Endoscopic variceal ligation

Video Endoscopic Sequence 3 of 15.

Continuing with the process of ligation.

Endoscopic variceal ligation

Video Endoscopic Sequence 4 of 15.

Image and video clip, immediately after performingtherapy with bands.

Apparently this was the varix, which subsequently caused the hemorrhage, despite having been ligated. Bleeding is observed in some of the next video clips-

Endoscopic variceal ligation

Video Endoscopic Sequence 5 of 15.

Another image and video clip, in hindsight, this varix was the cause of bleeding after the ligation with bands. Note redness and edema slight bleeding, and the strangulation of the varix was adequate.


Endoscopic variceal ligation

Video Endoscopic Sequence 6 of 15.

Two days after the therapeutic treatment with bands, he started with severe bleeding in the upper digestive system which is expressed with hematemesis and melena.

Endoscopic variceal ligation

Video Endoscopic Sequence 7 of 15.

This image, and in the video clip shows the varix that causes this severe episode of bleeding. Enough water was used to clear and wash the bleeding.
.


Endoscopic variceal ligation

Video Endoscopic Sequence 8 of 15.

This endoscopy shows suctioning and washing the bleeding

Endoscopic variceal ligation

Video Endoscopic Sequence 9 of 15.

To perform hemostasis using argon plasma coagulator which must be worn without making contact.

Endoscopic variceal ligation

Video Endoscopic Sequence 10 of 15.

Carefully, argon plasma was used to perform hemostasis.

Endoscopic variceal ligation

Video Endoscopic Sequence 11 de 15.

It continues to monitor the variceal bleeding caused after two days, after having placed the banding. At this time it was necessary to decide the next step which would place another band on this, sclerotherapy, or leave it alone. I think that with this observation it would have been better to place another band, however we use the argon plasma. Note: in another clinical case a patient, after having multiple sessions with rubber bands ligations by fibrosis caused by cicatrization (which is normal in the healing of the ligated varices), the patient begins with several episodes of bleeding. The exact site was located in the middle of fibrosis, which was only a blood clot in the middle of the one third of the esophagus. We proceeded to evaluate the hemostatic procedures an decided to place two bands. We were not really sure if the bands could play a role, and that hemostatic because the fibrosis could slip the bands one-by-one, and effectively reintroduce the endoscope with the air of the bands that were slipped. Caused severe bleeding which was successfully managed using a dual-channel endoscope and argon plasma coagulation. In this former case because the fibrosis we would recomended to use sclerotherapy.


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Endoscopic variceal ligation

Video Endoscopic Sequence 12 of 15.

There are multiple varices without being ligated, coagulation process is continuous with argon wich coagulates the surface of the varix.


Endoscopic variceal ligation

Video Endoscopic Sequence 13 of 15.

This video clip shows that the argon plasma is used too close sticking the tissue and removing it. Causing a severe bleeding.
A bleeding hole is observedAt this moment, we were analyzing if it had used hemoclips or injected histoacryl.

 

 



argon plasma coagulation

Video Endoscopic Sequence 14 of 15.

It follows using argon plasma coagulation


sclerotherapy varices Esophagus

Video Endoscopic Sequence 15 de 15.

To stop the bleeding after argon plasma is used sclerotherapy is carry out.

Esophageal Varices

Video Endoscopic Sequence 1 of 8.

This is the case of a 16 year-old woman, who since age 4, was diagnosed with autoimmune hepatitis and had been treated with immunosuppressants in the national children's hospital, reaches our emergency unit because of bleeding from the upper gastrointestinal tract, immediately an emergency endoscopy was performed detecting the cause of bleeding that are esophageal varices and rubber bands treatment was carry out.

In the Image and the video clip show some varices with fibrin, determined the cause and exact location of this hemorrhage.

 

 

Esophageal Varix

Video Endoscopic Sequence 2 of 8.

Some varices are seen in retroflexion, some with fibrin

Esophageal Varix

Video Endoscopic Sequence 3 of 8.

In the gastroesophageal junction there are varices with the red sign.

 

rubber band ligation

Video Endoscopic Sequence 4 of 8.

Endoscopic rubber band ligation in treatment of esophageal varices bleeding

 




rubber band ligation

Video Endoscopic Sequence 5 of 8.

Six varices were ligated

 





rubber band ligation

Video Endoscopic Sequence 6 of 8.

There was no recurrence of bleeding

Jaundice

Video Endoscopic Sequence 7 of 8.

Jaundice was marked, total serum bilirubin measurements were 35 mg/dL

 


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Jaundice

Video Endoscopic Sequence 8 of 8.

 

 

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