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 65 year-old 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 evaluated 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 sites of bleeding was identified.

Video Endoscopic Sequence 1 of 15.

 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.).

 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.

Two angiectasias was found at the gastric body.

Video Endoscopic Sequence 2 of 15.

Two angiectasias were found at the gastric body.

 Endoscopic Image of bleeding of Esophageal Varix . At the at the time of being exploring the stomach, the patient present a cough reflex, causing re bleeding 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.

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.

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.

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.

Immediately, a therapeutically approach was carry out with banding.

Video Endoscopic Sequence 5 of 15.

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

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

Video Endoscopic Sequence 6 of 15.

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.

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.

Video Endoscopic Sequence 7 of 15.

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.

 

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.

Video Endoscopic Sequence 8 of 15.

 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.

 

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.

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.

 

Patient with Cirrhosis of the liver with 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.

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

 

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.

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.

 

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).

Video Endoscopic Sequence 12 of 15.

 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).

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%.

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%.

 

VarixAngelic13

Video Endoscopic Sequence 14 of 15.

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

VarixAngelic14

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 the
 amount 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.

 

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. .

Video Endoscopic Sequence 1 of 10.

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.

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

Video Endoscopic Sequence 2 of 10.

 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.

 

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

Video Endoscopic Sequence 3 of 10.

 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.

 

 

More images and video clips of the exact site of the bleeding.

Video Endoscopic Sequence 4 of 10.

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

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

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 requires placement of an opaque cylinder over the end of the endoscope.

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.

 

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

Video Endoscopic Sequence 8 of 10.

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

 More bands were applied to several varices.

Video Endoscopic Sequence 9 of 10.

 More bands were applied to several varices.

More varices have been ligated.

Video Endoscopic Sequence 10 of 10.

More varices have been ligated.

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

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.

 
                                          Medline.

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.

Video Endoscopic Sequence 2 of 26.

Radial Endosonography.

 The intraluminal varices are being compressed by the
 water-filled balloon, and are hardly visible on the
 endosonographic image.

 Varices are identified as multiple, well-circumscribed,
 hypoechoic or anechoic structures that have a tubular or
 serpinginous appearance; they are located in the
 submucosal layer.

 Download the video clip by clicking on the endosonographic
 image.
                                       
   Medline.

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.




                                         
                                          Medline.  

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 identifed, then gently sucked up into the cap and the band deployed around the varix. A second site just proxial to the first is next selected and this is banded. This process is continued until all the bands are deployed.

Video Endoscopic Sequence 4 of 26.

 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.
                                        
                                     Medline

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.

 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.

                                           Medline.

  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.

 

 

                                           
                                           Medline.

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.

 

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 areresponsible for the main complication of portal hypertension and massive upper GI hemorrhage.

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.
 B
anding 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).

More images and video clip of post 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.
 E
ndoscopic 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.
 T
he evolution of the patient has been satisfactory to date.

 

LiagaMey1

Video Endoscopic Sequence 1 of 6.

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

LiagaMey2

Video Endoscopic Sequence 2 of 6.

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

 

LiagaMey3

Video Endoscopic Sequence 3 of 6.

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

 

LiagaMey4

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%).

 

 

LiagaMey5

Video Endoscopic Sequence 5 of 6.

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.

LiagaMey6

Video Endoscopic Sequence 6 of 6.

 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.

 

PostBandingBleeeeding11

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.

 

PostBandingBleeeeding12

Video Endoscopic Sequence 2 of 15.

In this first session six varices were ligated.

 

PostBandingBleeeeding13

Video Endoscopic Sequence 3 of 15.

 Continuing with the process of ligation

 

PostBandingBleeeeding14

Video Endoscopic Sequence 4 of 15.

Image and video clip, immediately after performing
therapy 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.

PostBandingBleeeeding15

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.

PostBandingBleeeeding1

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.

 

PostBandingBleeeeding2

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.

PostBandingBleeeeding3

Video Endoscopic Sequence 8 of 15.

This endoscopy shows suctioning and washing the bleeding

 

PostBandingBleeeeding4

Video Endoscopic Sequence 9 of 15.

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

PostBandingBleeeeding5

Video Endoscopic Sequence 10 of 15.

Carefully argon plasma was used to perform hemostasis

 

PostBandingBleeeeding6

Video Endoscopic Sequence 11 of 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 and
 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. 

 I'm locating the video clip to process and place in this atlas.

PostBandingBleeeeding7

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.

PostBandingBleeeeding8

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 observed.

At this moment, we were analyzing if it had used hemoclips or injected histoacryl.

PostBandingBleeeeding9

Video Endoscopic Sequence 14 of 15.

It follows using argon plasma coagulation

 

PostBandingBleeeeding10

Video Endoscopic Sequence 15 of 15.

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