Endoscopic Variceal ligation
Endoscopic Variceal ligation

Video Endoscopic Sequence 1 of 10.

Endoscopic Variceal ligation

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 ago, 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.


Endoscopy of Variceal ligation

Video Endoscopic Sequence 2 of 10.

Endoscopy of Variceal ligation

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.


 

Endoscopic application of rubber band onto the bleeding

Video Endoscopic Sequence 4 of 10.

Endoscopic application of rubber band onto the bleeding
site.

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

Endoscopic application of rubber band onto the bleeding

Video Endoscopic Sequence 5 of 10.

Endoscopic application of rubber band onto the bleeding site.

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.

 

Endoscopic application of rubber band onto the bleeding

Video Endoscopic Sequence 6 of 10.

Endoscopic application of rubber band onto the bleeding site.

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.

 

Video Endoscopic Sequence 7 of 10.

Endoscopic application of rubber band onto the bleeding site.

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

 

Endoscopic Variceal ligation

Video Endoscopic Sequence 8 of 10.

Endoscopic Variceal ligation

Esophageal varix which have been successfully banded.

The varix was successfully ligated.

Video Endoscopic Sequence 9 of 10.

The varix was successfully ligated.


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

Sclerotherapy of adjacent tissues

Video Endoscopic Sequence 10 of 10.

Sclerotherapy of adjacent tissues

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.

Banding of Esophageal Varices.

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 overcame, 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.



Endoscopic Variceal ligation

Video Endoscopic Sequence 2 of 19.

Endoscopic Variceal ligation

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.

Endoscopic Variceal ligation

Video Endoscopic Sequence 3 of 19.

Endoscopic Variceal ligation

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.

 

 

Endoscopy of Variceal ligation

Video Endoscopic Sequence 4 of 19.

Endoscopy of Variceal ligation

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.


 

Endoscopic variceal ligation (banding).

Video Endoscopic Sequence 5 of 19.

Endoscopic variceal ligation (banding).

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.


Banding of Esophageal Varices

Video Endoscopic Sequence 6 of 19.

Banding of Esophageal Varices

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

Video Endoscopic Sequence 7 of 19.

Banding of Esophageal Varices

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


Endoscopy of Variceal ligation

Video Endoscopic Sequence 8 of 19.

Endoscopy of Variceal ligation

In this image and video we can observe another band placement and other varices already treated at the lower portion of the esophagus.

The varices were successfully ligated.

Video Endoscopic Sequence 9 of 19.

Endoscopic Variceal ligation

The varices were successfully ligated.

In the video you can observe the varix with its
band. Other varices with bands can also be seen.

The varix was successfully ligated.

Video Endoscopic Sequence 10 of 19.

The varix was successfully ligated.

You can observe the strangulated varix. Other varices with bands can be seen.

Endoscopic Variceal ligation

Video Endoscopic Sequence 11 of 19.

Endoscopic Variceal ligation

The varices were successfully ligated.

 


 

The varices shown signs of necrosis

Video Endoscopic Sequence 12 of 19.

A follow-up 8 days later.

The varices shown signs of necrosis.


Endoscopic Variceal ligation

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.

Video Endoscopic Sequence 14 of 19.

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

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.
 

Video Endoscopic Sequence 16 of 19.

Some varices of the cardias in retroflexed image.



Video Endoscopic Sequence 17 of 19.

The video clip displays a long tract of the esophagus
displaying multiple varices.

 

Video Endoscopic Sequence 18 of 19.

Six varices were ligated at this time.

variceal banding

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.

 

variceal banding

Video Endoscopic Sequence 1 of 10.

This 62 year-old physician, with alcoholic cirrhosis presented his first bled due to esophageal varix, undergone variceal banding, six bands were placed.

variceal banding

Video Endoscopic Sequence 2 of 10.

Large esophageal varices are seen.

variceal banding

Video Endoscopic Sequence 3 of 10.

A banding apparatus was fitted to the end of the
endoscope.The image and video clip show the variceal
therapy with banding.

variceal banding

Video Endoscopic Sequence 4 of 10.


Varices with Banding Therapy.

variceal banding

 Video Endoscopic Sequence 5 of 10.

Eradication of the esophageal varices by endoscopic band ligation. Scars in the esophageal wall.

After 3 session with banding, most of the varices were irradicated, the image and the video clip shows the scars.

 

variceal banding

Video Endoscopic Sequence 6 of 10.

Several scars are seen in this area.

Band ligation is now considered the first-line endoscopic therapy for esophageal varices. The band ligator is readily attached to the distal end of the endoscope, which is advanced to the varix; the endoscopist then suctions the varix into the ligator cap and deploys a rubber band around the varix. This results in the plication of the varices and surrounding submucosal tissue, with fibrosis and eventual obliteration of varices.

 

variceal banding

Video Endoscopic Sequence 7 of 10.

After one week of the latest session of banding, patient presented with an upper bleeding that was due to the site of a varix that was falled off.

argon plasma coagulation (APC)

Video Endoscopic Sequence 8 of 10.

In order to stop the hemorrhage, the argon plasma coagulator is used to coagulate the exact site of the bleed.

argon plasma coagulation (APC)

Video Endoscopic Sequence 9 of 10.

The blue light of the APC is seen.

The argon plasma coagulation (APC) is used to promote mucosal fibrosis and compared the efficacy of ligation plus APC with ligation alone in the treatment of esophageal varices.


Argon Plasma Coagulation APC

Video Endoscopic Sequence 10 of 10.

The final Status of the coagulation with Argon Plasma Coagulator, the hemorrhage has been stopped successfully. 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.

This patient has had no further bleeding.


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