Variceal Hemorrhage
Variceal Hemorrhage.

Video Endoscopic Sequence 1 de 4.

Variceal Hemorrhage.

A 74 year-old female. Two months previously 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.

Portal hypertension is a progressive complication of cirrhosis. Therefore, the management of the patient with cirrhosis and portal hypertensive gastrointestinal bleeding depends on the phase of portal hypertension at which the patient is situated, from the patient with cirrhosis and portal hypertension who has not yet developed varices to the patient with acute variceal hemorrhage for whom the objective is to control the active episode and prevent rebleeding.

Each endoscopic image of this atlas has a video clip




 

Endoscopy Shows the exact site of the bled

Video Endoscopic Sequence 2 de 4.

Endoscopy Shows the exact site of the bled

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.


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Endoscopic application of rubber band onto the bleeding

Video Endoscopic Sequence 3 de 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.

Video Endoscopic Sequence 4 de 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).

Consists of the placement of rubber rings on variceal columns which are sucked into a plastic hollow cylinder attached to the tip of the endoscope. Multiple-shot devices have largely replaced the original single-shot ligators, since the procedure is much simpler and faster with multishot devices, and an overtube is not required, thus avoiding the severe complications related to its use. Furthermore, new transparent caps are available which improve the visibility (visibility with the old caps may be reduced by 30%.

Several commercial multiband devices are available for EBL. They have 4-10 preloaded bands. All have the same principle. i.e., placement of elastic bands on a varix after it is sucked into a clear plastic cylinder attached to the tip of the endoscope.



Endoscopy of Variceal ligation

Video Endoscopic Sequence 1 de 11.

Endoscopy of Variceal ligation

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 clip show the status post ligation.



Endoscopy of Variceal ligation

Video Endoscopic Sequence 2 de11.

Endoscopy of Variceal ligation

The images and the video clips display some varices that have been ligated and some post ligated ulceration.




Endoscopy of Variceal ligation

Video Endoscopic Sequence 3 de 11.

Endoscopy of Variceal ligation

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.

 

Endoscopy of Variceal ligation

Video Endoscopic Sequence 4 de 11.

Endoscopy of Variceal ligation

An esophageal varix that was ligated seen with magnifying.

 

Endoscopy of Variceal ligation

Video Endoscopic Sequence 5 de 11.

Endoscopy of Variceal ligation

Another varix appreciated with a magnifying endoscope.



Endoscopy of Variceal ligation

Video Endoscopic Sequence 6 de 11.

Endoscopy of Variceal ligation

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

Endoscopy of Variceal ligation

Video Endoscopic Sequence 7 de 11.

Endoscopy of Variceal ligation

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


 

Endoscopic Variceal ligation

Video Endoscopic Sequence 8 de 11.

Endoscopic Variceal ligation

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

 

 

 



Endoscopic Variceal ligation

Video Endoscopic Sequence 9 de 11.

Endoscopic Variceal ligation

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.

 

 

Endoscopic Variceal ligation

Video Endoscopic Sequence 10 de 11.

Endoscopic Variceal ligation

One ulceration post varix ligation is displayed


 

Endoscopic Variceal ligation

Video Endoscopic Sequence 11 de 11.

Endoscopic Variceal ligation

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.

 

Post variceal ligation hemorrhage

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.



Endoscopy shows Presence of multiple cherry red spots.

Video Endoscopic Sequence 2 of 17.

Endoscopy shows 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.

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

Video Endoscopic Sequence 4 of 17.

Endoscopic view of Banding of Esophageal Varices.

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

 

 




Banding of Esophageal Varices

Video Endoscopic Sequence 5 of 17.


Endoscopy of Variceal Banding

In this image and the video clip shows that the varices with
the red spot were ligated.


Endoscopic Variceal ligation

Video Endoscopic Sequence 6 of 17.

Endoscopic Variceal ligation

This picture as well as the video clip display some varices with the red sign that were ligated.



Endoscopic Variceal ligation

Video Endoscopic Sequence 7 de 17.

Endoscopic Variceal ligation

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.

 

Endoscopic Variceal ligation

Video Endoscopic Sequence 8 de 17.




Acute Variceal Bleed

Video Endoscopic Sequence 9 de 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 the bleeding.

Life-threatening bleeding caused by early spontaneous slippage of rubber bands has been described after variceal ligation in cirrhotic patients.

Bleeding related to post-banding ulcer is a rare, but severe complication. The proposed predictive factors should be looked for and minimized before variceal ligation.



Acute Variceal Bleed

Video Endoscopic Sequence 10 de 17.

Acute Variceal Bleed

There are two possible sites of the bleeding two varices that were previously ligated, hemostatic maneuver has been applied with APC.

In cirrhotic patients, esophageal variceal bleeding (EVB) is still unpredictable and continues despite initial adequate treatment that is associated with great mortality. Bacterial infections are frequently diagnosed in cirrhotic patients with gastrointestinal bleeding (GIB). The aims of this study were to analyze the clinical risk factors and survival of early bleeding after endoscopic variceal ligation (EVL).

Acute Variceal Bleed

Video Endoscopic Sequence 11 de 17.

Acute Variceal Bleed

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

Bacterial infection and end-stage liver cirrhosis (Child C) are the independent risk factors for early bleeding after EVL. We should closely monitor the symptoms/signs of infection and empirical antibiotics should be administered once infection is suspected or documented, especially in cirrhotic patients with poor liver reserve.



Acute Variceal Bleed

Video Endoscopic Sequence 12 de 17.

Management of acute variceal bleeding consists of pharmacologic and endoscopic treatment. Endoscopic techniques currently used to stop variceal bleeding are endoscopic sclerotherapy, variceal obturation with glue and endoscopic band ligation (EBL). EBL is the endoscopic treatment of choice because it is an effective treatment for bleeding from esophageal varices. It is generally accepted and recommended for the treatment of acute bleeding events. EBL is also used for the secondary prophylaxis of esophageal variceal hemorrhage.

 

 

Acute Variceal Bleed

Video Endoscopic Sequence 13 de 17.

More hemostatic maneuver with APC.

 

 

Acute Variceal Bleed

Video Endoscopic Sequence 14 de 17.

 

 

Acute Variceal Bleed

Video Endoscopic Sequence 15 de 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.

 



Acute Variceal Bleed

Video Endoscopic Sequence 16 de 17.

Portal hypertension is a hemostatic disorder that is often caused by liver cirrhosis. It is defined as an increase in blood pressure in the portal venous system. Portal hypertension can be the origin of severe complications in cirrhosis. Gastroesophageal varices are a potentially life-threatening complication of portal hypertension. Even though the outcome of bleeding from gastroesophageal varices has improved, it is still associated with a high mortality rate. The mortality rate of acute variceal bleeding has decreased from 42% in 1981 to about 15% to 20% at present.

 

 

Acute Variceal Bleed

Video Endoscopic Sequence 17 de 17.

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

Risk factors for bleeding from esophageal varices have been identified in several randomized controlled trials (RCT). Poor Child-Pugh score, bacterial infection, elevated aspartate amino transferase levels, and a hepatic venous pressure gradient greater than 20 mmHg, measured shortly after admission, are associated with a higher bleeding rate.

 

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