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 Sequence displays banding of esophageal varices. Endoscopic variceal ligation, a less invasive procedure than endoscopic sclerotherapy.

Video Endoscopic Sequence 1 of 17.

 This Sequence displays banding of esophageal varices.
 Endoscopic variceal ligation, a less invasive procedure
 than endoscopic sclerotherapy.

 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.

The esophageal varices are seen in retroflexed view. Esophageal varices eventually develop in most patients with cirrhosis, but variceal bleeding occurs in only one third of them. Treatment of patients at highest risk for bleeding is critical because of the high risk of death with each episode of variceal hemorrhage. The goal of treatment of portal hypertension is decreased variceal flow, which is achieved by reducing either portal venous inflow or resistance to portal outflow.

Video Endoscopic Sequence 2 of 17.

 The esophageal varices are seen in retroflexed view.

 Esophageal varices eventually develop in most patients
 with cirrhosis, but variceal bleeding occurs in only one third
 of them. Treatment of patients at highest risk for bleeding
 is critical because of the high risk of death with each
 episode of variceal hemorrhage. The goal of treatment of
 portal hypertension is decreased variceal flow, which is
 achieved by reducing either portal venous inflow or
 resistance to portal outflow.
suction is applied through the endoscope, and the band is released over the entrapped varix . The clear plastic cylinder of the variceal ligation device is seen attached to the end of the endoscope. 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.

Video Endoscopic Sequence 3 of 17.

 Suction is applied through the endoscope, and the band is
 released over the entrapped varix.

 The clear plastic cylinder of the variceal ligation device is
 seen attached to the end of the endoscope.

 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.
More bands have been placed on the varices, resulting in spherical blebs. Note the colored elastic bands strangulating each varix at the base. A typical appearance after a band has been placed at its base. Below the small circular band, which failed to deliver properly is observed.

Video Endoscopic Sequence 4 of 17.

 More bands have been placed on the varices, resulting in
 spherical blebs. Note the colored elastic bands
 strangulating each varix at the base.
 A typical appearance after a band has been placed at its
 base.
 Below the small circular band, which failed to deliver
 properly is observed.

As seen through the banding apparatus attached to the tip of the endoscope. Ligation therapy has been used for years as the treatment of hemorrhoids, and the technique was modified for the treatment of esophageal varices.

Video Endoscopic Sequence 5 of 17.

 As seen through the banding apparatus attached to the tip
 of the endoscope.
 Ligation therapy has been used for years as the treatment
 of hemorrhoids, and the technique was modified for the
 treatment of esophageal varices.
The video clip displays two varices with typical appearance after a band has been placed at its base. Variceal hemorrhage accounts for one third of all deaths related to cirrhosis. To date, many modalities of treating variceal bleeding have been devised, including pharmacological therapy. Treatment of variceal hemorrhage includes resuscitation, initial hemostasis, and prevention of complications and recurrent bleeding. Intravenous vasoactive agents such as terlipressin, somatostatin, octreotide, or vapreotide should be administered in patients with suspected variceal bleeding. Endoscopic treatment remains the mainstay of treatment.

Video Endoscopic Sequence 6 of 17.

 The video clip displays two varices with typical
 appearance after a band has been placed at its base.

 Variceal hemorrhage accounts for one third of all deaths
 related to cirrhosis. To date, many modalities of treating
 variceal bleeding have been devised, including
 pharmacological therapy. Treatment of variceal
 hemorrhage includes resuscitation, initial hemostasis, and
 prevention of complications and recurrent bleeding.
 Intravenous vasoactive agents such as terlipressin,
 somatostatin, octreotide, or vapreotide should be
 administered in patients with suspected variceal bleeding.
 Endoscopic treatment remains the mainstay of treatment.

 
A varix has been ligated at the cardias.

Video Endoscopic Sequence 7 of 17.


        A varix has been ligated at the cardias.

 
Retroflexed view of cardias, the video clip display four varices that have been banding.

Video Endoscopic Sequence 8 of 17.

 Retroflexed view of cardias, the video clip display four
 varices that have been banding.

 
The video clip displays two varices that have been banding. Note the raised mucosal bleb (the varix) with a black band at the base.

Video Endoscopic Sequence 9 of 17.

 The video clip displays two varices that have been banding.
 Note the raised mucosal bleb (the varix) with a black band
 at the base.
 
 
Follow up, 5 days after the banding. An endoscopy was performed to follow up the banding treatment, the four varices were with necrotic appearance. Similar of the treatment for hemorrhoids with banding.

Video Endoscopic Sequence 10 of 17.

           Follow up, 5 days after the banding.

 An endoscopy was performed to follow up the banding
 treatment; the four varices were with necrotic appearance.
 similar of the treatment for hemorrhoids with banding.
 
Another image and video of the follow up some varices are seen with white color due to necrosis exerted by the bands.

Video Endoscopic Sequence 11 of 17.

 Another image and video of the follow up some varices
 are seen with white color due to necrosis exerted by the
 bands. 
Two necrotic varices are appreciated at the cardias.

Video Endoscopic Sequence 12 of 17.

 Two necrotic varices are appreciated at the cardias.

  
Retroflexed image, an ulceration is observed where the band was come off, attach to the endoscope a fibrin fragment is observed which recently has been fallen from this ulceration.

Video Endoscopic Sequence 13 of 17.

 Retroflexed image, an ulceration is observed where the
 band was come off, attach to the endoscope a fibrin
 fragment is observed which recently has been fallen from
 this ulceration.
 

 
A new follow up, after two weeks of the variceal band treatment. Status post treatment was observed, some ulcers where the varices were found. The rubber band has already fallen off, leaving behind an oozing ulcer.

Video Endoscopic Sequence 14 of 17.

 A new follow up after two weeks of the variceal band
 treatment. Status post treatment was observed, some
 ulcers where the varices were found. 
 The rubber band has already fallen off, leaving behind an
 oozing ulcer.

The image and the video show multiple oozing ulcer.

Video Endoscopic Sequence 15 of 17.

 The image and the video show multiple oozing ulcer.
Another post ligation ulcer is observed retroflexed image.

Video Endoscopic Sequence 16 of 17.

 Another post ligation ulcer is observed retroflexed image.
 
 See the video clip.

This image shows the status of variceal banding. The scope is retroflexed in the stomach to check for gastric varices, none are seen. The ulcer is seen at the gastric cardias. Because varices tend to recur over time, surveillance endoscopy must be performed every 6 to 12 months so that banding can be reinstituted as needed. Repeated endoscopic treatment eradicates esophageal varices in most patients, and provided that follow up is adequate serious recurrent variceal bleeding is uncommon. Because the underlying portal hypertension persists, patients remain at risk of developing recurrent varices and therefore require lifelong regular surveillance endoscopy.

Video Endoscopic Sequence 17 of 17.

 This image shows status post variceal banding.
 The scope is retroflexed in the stomach to check for gastric
 varices, none are seen.
 The ulcer is seen at the gastric cardias.
 Because varices tend to recur over time, surveillance
 endoscopy must be performed every 6 to 12 months so that
 banding can be reinstituted as needed.
 Repeated endoscopic treatment eradicates esophageal
 varices in most patients, and provided that follow up is
 adequate serious recurrent variceal bleeding is uncommon.
 Because the underlying portal hypertension persists,
 patients remain at risk of developing recurrent varices and
 therefore require lifelong regular surveillance endoscopy.

Sequences of images and videos of a case on hemorrhage due status post rubber band ligation of esophageal varices. A 77 year-old female, one month previously she started with her first hematemesis, she was hospitalized in a National Hospital called " Hospital Rosales". She was stabilized with intavenous liquid and blood transfusion. The hemorrhage was stopped with the Minnesota balloon. After that, 4 rubber bands were placed in the middle third of the esophagus.

Video Endoscopic Sequence 1 of 25.

 Sequences of images and videos of a case on hemorrhage
 due status post rubber band ligation of esophageal varices.
 A 77 year-old female, one month previously she started with
 her first hematemesis, she was hospitalized in a National
 Hospital called “ Hospital Rosales”. She was stabilized
 with intavenous liquid and blood transfusion.
 The hemorrhage was stopped with the Minnesota balloon.
 After that, 4 rubber bands were placed in the middle third of
 the esophagus. 

SStatus post rubber band ligation of esophageal varices. Some ulcers are observed, one of them with vessel and blood clots. "Stigmata of Bleeding". Ligation therapy has been used for years as treatment of hemorrhoids, and the technique was modified for the treatment of esophageal varices.

Video Endoscopic Sequence 2 of 25.

 Status post rubber band ligation of esophageal varices.

 Some ulcers are observed, one of them with vessel and
 blood clots.
              “Stigmata of Bleeding”.

 Ligation therapy has been used for years as treatment of
 hemorrhoids, and the technique was modified for the
 treatment of esophageal varices.
 
Sclerotherapy Versus Banding for Variceal Bleeding. Endoscopic sclerotherapy also reduces the rate of rebleeding, although overall mortality is not affected. The main disadvantage of endoscopic sclerotherapy is the variable incidence of local and systemic complications, with serious complications occurring in 10-20% of patients, leading to a 2-5% procedure-related mortality. Multiple studies have demonstrated that variceal ligation has a remarkably low complication rate. A number of studies have been completed to compare the efficacy and safety of endoscopic sclerotherapy versus endoscopic variceal ligation. These studies demonstrate that ligation is equally as effective as sclerotherapy in achieving control of acute variceal bleeding. On the basis of the results of a number of trials comparing sclerotherapy with band ligation, endoscopic variceal ligation has evolved to be the preferred first line modality for the endoscopic treatment of esophageal variceal bleeding.

Video Endoscopic Sequence 3 of 25.

 Sclerotherapy Versus Banding for Variceal Bleeding.
 Endoscopic sclerotherapy also reduces the rate of
 rebleeding, although overall mortality is not affected. The
 main disadvantage of endoscopic sclerotherapy is the
 variable incidence of local and systemic complications, with
 serious complications occurring in 10-20% of patients,
 leading to a 2-5% procedure-related mortality. Multiple
 studies have demonstrated that variceal ligation has a
 remarkably low complication rate. A number of
 studies have been completed to compare the efficacy and
 safety of endoscopic sclerotherapy versus endoscopic
 variceal ligation. These studies demonstrate that ligation is
 equally as effective as sclerotherapy in achieving control of
 acute variceal bleeding.
 On the basis of the results of a number of trials comparing
 sclerotherapy with band ligation, endoscopic variceal
 ligation has evolved to be the preferred first line modality
 for the endoscopic treatment of esophageal variceal
 bleeding.
 
Retroflexed view in the esophagus some ulcers are observed to the left side.

Video Endoscopic Sequence 4 of 25.

 Retroflexed view in the esophagus some ulcers are
 observed to the left side.
 

 

Status post Minnesota tube insertion. Necrosis and ulceration are appreciated.

Video Endoscopic Sequence 5 of 25.

 Status post Minnesota tube insertion. Necrosis and
 ulceration are appreciated.
 Retroflexed view of the cardias.          

Frontal view of the cardias. There are some ulceration at this level due to a Minnesota tube.

Video Endoscopic Sequence 6 of 25.

 Frontal view of the cardias. There are some ulceration at
 this level due to a Minnesota tube.
      
Sclerotherapy injection of the bleeding area of the status post rubber band ligation.

Video Endoscopic Sequence 7 of 25.

 Sclerotherapy injection of the bleeding area of the status
 post rubber band ligation.
 Polydocanol 0.75% was used. 
 
Successfully injected, bleeding did not recur. This sclerotherapy proved to be a life-saving procedure.

Video Endoscopic Sequence 8 of 25.

 Successfully injected, bleeding did not recur.
 This sclerotherapy proved to be a life-saving procedure. 
 The patient was discharged from the hospital on the next
 day.
12 days after the first sclerotherapy, we performed a second elective session of variceal injection. The sequences of images and videos display this procedure. We planned to inject four further varices on this day, Note the scar tissue on the right side of the image above due to status post variceal ligation.

            Video Endoscopic Sequence 9 of 25.

 12 days after the first sclerotherapy, we performed a
 second elective session of variceal injection. The
 sequences of images and videos display this procedure.
 We planned to inject four further varices on this day,
 Note the scar tissue on the right side of the image above
 due to status post variceal ligation.
1.5 ml of Polydocanol at 1.5% was injected with a 4.15 minute time delay before the injector was retracted.

Video Endoscopic Sequence 10 of 25.

 1.5 ml of Polydocanol at 1.5% was injected with a 4.15
 minute time delay before the injector was retracted.
The image and video display the retraction caused by the injector as well as a slight hemorrhage which originates in the variceal wall.

Video Endoscopic Sequence 11 of 25.


 The image and video display the retraction caused by the
 injector as well as a slight hemorrhage which originates in
 the variceal wall.

This image and the video show the third sclerotherapy applied on a large vein which presented with various red signs. 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.

Video Endoscopic Sequence 12 of 25.

 This image and the video show the third sclerotherapy
 applied on a large vein which presented with various red
 signs.
 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.
Maintaining a certain force on the injector during 4 minutes Polydocanol was injected.

Video Endoscopic Sequence 13 of 25.

 Maintaining a certain force on the injector during 4 minutes
 Polydocanol was injected.
The injector is retracted and a small ulcer is observed as a result of the injection.

Video Endoscopic Sequence 14 of 25.

 The injector is retracted and a small ulcer is observed as a
 result of the injection.

The fourth sclerotherapy is displayed in this image and the video.

Video Endoscopic Sequence 15 of 25.

 The fourth sclerotherapy is displayed in this image
 and the video.
  

Some bleeding is observed as a consequence of the sclerotherapy. The bleeding, which originated in the variceal wall, stopped spontaneously.

Video Endoscopic Sequence 16 of 25.

 Some bleeding is observed as a consequence of the
 sclerotherapy. The bleeding, which originated in the
 variceal wall, stopped spontaneously.
In sequence to the images presented above, you can see hemorrhage and blood clots, consequence of the last injection. The endoscopist needs to develop a certain degree of self-confidence.

Video Endoscopic Sequence 17 of 25.

 In sequence to the images presented above, you can see
 hemorrhage and blood clots, consequence of the last
 injection.
 The endoscopist needs to develop a certain degree of
 self-confidence.
This post-procedure control image shows no active bleeding. After a period of observation the procedure was considered complete. The patient was discharged from the hospital the next day.

 Video Endoscopic Sequence 18 of 25.

 This post-procedure control image shows no active
 bleeding. After a period of observation the procedure was
 considered complete. The patient was discharged from the
 hospital the next day.
 The image above displays some degree of hypertensive
 portal gastropathy. 

Two years later the patient re-bleeds, She had not taken a suitable medical control, the cirrhosis has progressed, now with ascitis. The hemoglobin was 6.0 gr/dl.

Video Endoscopic Sequence 19 of 25.

 Two years later the patient re-bleeds, She had not taken
 a suitable medical control, the cirrhosis has progressed,
 now with ascitis. The hemoglobin was 6.0 gr/dl.
The image and the video display bleeding from esophageal varix.

Video Endoscopic Sequence 20 of 25.

 The image and the video display bleeding from esophageal
 varix. 

Many varices are appreciated with red sign.

Video Endoscopic Sequence 21 of 25.

 Many varices are appreciated with “the red sign”.
The exactly site of bleeding was located at the anterior wall of the esophagus near two cm of the gastroesophageal junction.

Video Endoscopic Sequence 22 of 25.

 The exactly site of bleeding was located at the anterior wall
 of the esophagus near two cm of the gastroesophageal
 junction.

Another image and the video of the site of bleed.

Video Endoscopic Sequence 23 of 25.

 Another image and the video of the site of bleed.
We beging with the procedure to banding the varix.

Video Endoscopic Sequence 24 of 25.

 We beging with the procedure to banding the varix.
The bleeding has been stopped, tree varix were ligated. Patient was discharged from the hospital with an appointment to eradicate the varix with the same method

Video Endoscopic Sequence 25 of 25.

 The bleeding has been stopped, tree varix were ligated.
 Patient was discharged from the hospital with an
 appointment to eradicate the varix with the same method.
Banding of Esophageal Varices. Narrow endoscopic view through the rubber band delivery attachment placed on the tip of the endoscope. The variceal banding technique is similar to hemorrhoid banding and involves placing small elastic bands around varices in the distal 5 cm of the esophagus. Varices are suctioned into the banding device and bands are released around the base of the varix by pulling a trip wire via the biopsy channel. The advantages of band ligation over sclerotherapy include fewer local complications (secondary bleeding from ulcers or strictures), no systemic side effects, and the need for fewer treatments for variceal obliteration. Some of the drawbacks of band ligation include a restricted endoscopic view (due to the banding device and blood pooling within the hood mechanism), difficulty-performing treatments in the etroflexed position in the fundus of the stomach.

 Video Endoscopic Sequence 1 of 4.

Banding of Esophageal Varices.

 Narrow endoscopic view through the rubber band delivery
 attachment placed on the tip of the endoscope.
 The variceal banding technique is similar to hemorrhoid
 banding and involves placing small elastic bands around
 varices in the distal 5 cm of the esophagus. Varices are
 suctioned into the banding device and bands are released
 around the base of the varix by pulling a trip wire via the
 biopsy channel. The advantages of band ligation over
 sclerotherapy include fewer local complications (secondary
 bleeding from ulcers or strictures), no systemic side effects,
 and the need for fewer treatments for variceal obliteration.
 Some of the drawbacks of band ligation include a restricted
 endoscopic view (due to the banding device and blood
 pooling within the hood mechanism), difficulty-performing
 treatments in the retroflexed position in the fundus of the
 stomach.
Banding of Esophageal Varices. Two neighboring esophageal varices, which have been successfully banded. Note the improved view through the clear multi-banding apparatus. Note the raised mucosal bleb (the varix) with a black band at the base.

Video Endoscopic Sequence 2 of 4.

Banding of Esophageal Varices.

 Two neighboring esophageal varices, which have been
 successfully banded. Note the improved view through the
 clear multi-banding apparatus. Note the
 raised mucosal bleb (the varix) with a black band at the
 base.

Banding of Esophageal Varices.

Video Endoscopic Sequence 3 of 4.

             Banding of Esophageal Varices.
Banding of Esophageal Varices. Multiple studies have demonstrated that variceal ligation has a remarkably low complication rate. A number of studies have been completed to compare the efficacy and safety of endoscopic sclerotherapy versus endoscopic variceal ligation. These studies demonstrate that ligation is equally as effective as sclerotherapy in achieving control of acute variceal bleeding. rebleeding and mortality are less after variceal ligation. Also, the number of procedures required to achieve obliteration of varices is less with variceal ligation than with sclerotherapy in nearly all comparative studies. Finally, complications, both minor and major, appear to be less with variceal ligation than sclerotherapy.

Video Endoscopic Sequence 4 of 4.

 Multiple studies have demonstrated that variceal ligation
 has a remarkably low complication rate.
 A number of studies have been completed to compare the
 efficacy and safety of endoscopic sclerotherapy versus
 endoscopic variceal ligation. These studies demonstrate
 that ligation is equally as effective as sclerotherapy in
 achieving control of acute variceal bleeding.
 rebleeding and mortality are less after variceal ligation.
 Also, the number of procedures required to achieve
 obliteration of varices is less with variceal ligation than
 with sclerotherapy in nearly all comparative studies.
 Finally, complications, both minor and major, appear to be
 less with variceal ligation than sclerotherapy.