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 sitesofbleeding wereidentified.
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Video Endoscopic Sequence 2 of 9.
Two angiectasias was found at the gastric body.
Video Endoscopic Sequence 3 of 9.
At the at the time of being exploring the stomach, the patient present a cough reflex, causing re bleeding of the varix.
Video Endoscopic Sequence 4 of 9.
More images and video clips of this bleeding.
Video Endoscopic Sequence 5 of 9.
Immediately; a therapeutically approach was carry out with banding to the bleeding varix.
Video Endoscopic Sequence 6 of 9.
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 7 of 9.
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.
Video Endoscopic Sequence 8 of 9.
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 9 of 9.
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 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.
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.
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.
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
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.
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 8 of 26.
Magnifying view.
A large varix was ligated as is seen with magnifying endoscope.
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.
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.
Video Endoscopic Sequence 11 of 26.
Shallow ulcers at the site of each ligation are the rule and rarely bleed.
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).
Video Endoscopic Sequence 13 of 26.
One ulceration post varix ligation is appreciated (normal status).
Video Endoscopic Sequence 14 of 26.
More images and video clip of post banding status.
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.
Video Endoscopic Sequence 16 of 26.
Multiple scars are seen in this image and the video clip.
Video Endoscopic Sequence 17 of 26.
A retroflexed view of the esophagus is observed, the multiple scars of the status post banding are seen.
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.
Video Endoscopic Sequence 19 of 26.
In the video clip, you can see a bleeding from a small fissure at the gastroesophageal junction.
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.
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.
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.
Video Endoscopic Sequence 23 of 26.
One month after the previous images.
Six varices were ligated in this session.
Video Endoscopic Sequence 24 of 26.
Some fundic varices are observed.
Video Endoscopic Sequence 25 of 26.
Some varices are banding above of the multiple scars.
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.
