Severe upper gastrointestinal hemorrhage due to esophageal varices.
A 40 year-old, alcoholic male that has been drinking continuously for 3 months, a bottle of alcoholic beverage every day, came to the emergency room presenting severe hematemesis, The patient presented hypovolemic shock his average of arterial blood pressure was 70/40. He has a history of long standing alcohol adiction but no prior episodes of gastrointestinal bleeding.
Acute bleeding from esophageal varices requires an endoscopic evaluation and aggressive therapeutic intervention. Endoscopy in a patient with massive bleeding demands detail oriented atention. Adequate volume and blood replacement before and during endoscopy is vital, so is protection of the airway in a patient that is liable to aspiration. This may be achieved with endotracheal intubation.
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.
Video Endoscopic Sequence 2 of 41.
Larges varices are seen with the red sign.
1)Variceal bleeding is a complex medical emergency with a high mortality rate. 2) In managing this condition, special care must be exerted in maintaining vital functions and preventing complications. 3) Combination of endoscopic therapy plus a vasoactive drug is probably the most effective treatment for variceal bleeding.
Video Endoscopic Sequence 3 of 41.
The management of acute variceal bleeding is a complex process, which includes general supporting measures, resuscitation, cardiorespiratory monitoring, transfusion, treatment of the bleeding itself and prevention of complications. One frequently encountered difficulty is the pooling of blood near the fundus and the cardia, obscuring the endoscopic view. One method that is useful is to patiently suck out as much of blood from the fundus as possible, and to site the patient up. Blood in the oesophagus and the cardia will gravitate down, giving the opportunity to identify the bleeding points and targeted therapy Occasionally turning the patient to one the right side may expose the fundus.
Video Endoscopic Sequence 4 of 41.
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 5 of 41.
The major challenge for the endoscopist is to determine if the bleeding has been from esophageal, esophagogastric, or isolated gastric varices. In the absence of active bleeding or an obvious adherent or protruding clot, large distal esophageal varices (i.e., within 5 cm of the squamocolumnar junction) with red wale markings should be interpreted as the cause of bleeding. Endoscopic therapy should be initiated and directed at these varices. If the esophageal varices continue into the cardia, that is, are esophagogastric varices, endoscopic therapy should begin on the cardia side of the squamocolumnar junction because the gastric component of these varices usually can be eliminated. Once initiated, endoscopic therapy should most often be pursued with the eventual goal of eradication. After the initial treatment, endoscopic therapy is usually repeated in 5 to 7 days and then every 1 to 2 weeks until the distal esophageal varices are obliterated or reduced to a very small size. The interval between follow-up procedures tends to be longer (i.e., 2 weeks) in patients who have undergone variceal band ligation. Once eradicated, varices are typically reexamined in 6-month periods.
Video Endoscopic Sequence 6 of 41.
This image displays the exactly site of the bleeding at the cardias, active variceal bleeding is appreciated.
Diagnosis of the bleeding source. Endoscopy is an essential step in the diagnosis and treatment of acute variceal bleeding.
We recommend that you observe the video clip.
Video Endoscopic Sequence 7 of 41.
About 30% of patients with cirrhosis and portal hypertension bleed from ruptured esophageal varices. with a mortality for the initial bleed that may exceed 50% After a first bleed, untreated patients have a risk of rebleeding as high as 60%. The risk decreases with time, returning to baseline values by the sixth week after the variceal bleeding episode. Although gastric varices also bleed, little information is available on their natural history and their fate after endoscopic sclerotherapy of esophageal varices.
The goals of treatment in acute variceal bleeding are:
a. Correct hypovolaemia b. Stop bleeding as soon as possible c. Prevent early rebleeding d. Prevent complications e. Prevent deterioration of liver function.
Video Endoscopic Sequence 9 of 41.
This image and the video display active bleeding that is accumulated in the gastric fundus. Around the world there are diverses publications and experiences regarding varices many author disagree between each others concerning the Prophylaxis of first variceal bleeding but we enphatizedthat variceal banding should be performed to any patient with esophageal varices, whatever the degree or risk factors for variceal bleeding. Simply we are convinced of its effectiveness and almost noncomplications and mainly of great benefit in the eradication of these varices.
Video Endoscopic Sequence 10 of 41.
The image and the video display active variceal bleeding that is appreciated through the banding apparatus.
Emergency endoscopic therapy requires a skilled endoscopist.
Banding ligation was first reported in humans in 1989 and represents an important development in the endoscopic treatment of varices. Since its introduction, endoscopic variceal banding has been shown to be superior to needle sclerotherapy. It consists of the placement of rubber O-rings on variceal columns, which are sucked into a hollow cylinder attached to the tip of the endoscope. In the acute situation, hemostasis is achieved by physical constriction of the varix at or near the bleeding site, thus interrupting blood flow. In the following days, ischemic necrosis of mucosa and submucosa develops, followed by granulation tissue formation and sloughing of the O-rings and of the necrotic tissue, which leave shallow mucosal ulcerations. Complete reepithelialization takes place in 14-21 days, with full-thickness replacement of the vascular structures with maturing scar tissue.
Video Endoscopic Sequence 11 of 41.
The endoscopic tip is at the cardias, active variceal bleeding emerged into the banding apparatus.
Alcoholism is the most common cause of portal hypertension, but hepatitis B and hepatitis C are increasingly seen ascauses of posthepatic cirrhosis. Hepatocellular carcinomamay complicate hepatitis B and result in sudden onset ofportal hypertension with portal vein thrombosis and bleeding. In patients with cirrhosis and portal hypertension.
Video Endoscopic Sequence 12 of 41.
The varix is suctioned into the banding apparatus.
Video Endoscopic Sequence 13 of 41.
Endoscopic variceal ligation (banding).
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. 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. Recent trials have demonstrated that ligation and sclerotherapy achieved similar rates of initial hemostasis in patients whose varices were actively bleeding at the time of treatment. Local complications are less common with ligation compared to sclerotherapy. For example, esophageal strictures were found to be less common with ligation compared to sclerotherapy. Systemic complications, such as pulmonary infections and bacterial peritonitis, were not significantly different in the 2 groups. However, a trend was observed toward a decrease in these 2 complications in patients treated with ligation.
Video Endoscopic Sequence 14 of 41.
The image as wellas the video clip displays the cardias with varix ligated. Variceal banding or sclerotherapy.Endoscopic therapy, particularly variceal banding (also called ligation), may be used to treat and prevent variceal bleeding in the esophagus. In the past, sclerotherapy was the main treatment to stop a first episode of variceal bleeding, but it has fallen out of favor. Most doctors now prefer variceal banding because it works as well as sclerotherapy to stop bleeding and has fewer complications.
Video Endoscopic Sequence 15 of 41.
Gastric cardias retroflexed maneuver, an erosionated varix is observed, more therapeutic with banding is planned.
Video Endoscopic Sequence 16 of 41.
Some banding were placed at the gastric fundus and colateral varices are observed, to place banding in the gastric fundus. We belive that can help in stop the bleeding but not medical literature was found it could be considered in the future.
Video Endoscopic Sequence 17 of 41.
Gastric cardias in retroflexed image, the ligated varix is seen with some color violet, beginning the necrosis. 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 18 of 41.
Gastric cardias is observed (retroflexed image).
Video Endoscopic Sequence 19 of 41.
This image and video display an erosionated varix at the cardia.
Video Endoscopic Sequence 20 of 41.
Status Post Banding.
The next day an upper endoscopy was performed, the varix of the cardias was fall of with necrotic area and no active bleeding was found. The rubber bands slough off in the following 24-72 hours, leaving a shallow ulcer behind. Ulceration is less severe than with sclerotherapy.
Video Endoscopic Sequence 21 of 41.
Status Post Banding.
At the cardias is seen with necrotic area where the varix was strangulated and another erosionated varix is observed.
Video Endoscopic Sequence 22 of 41.
The two banding of the fundus are observed as necrotic that are less than 24 hours.
Video Endoscopic Sequence 23 of 41.
The next day, an endoscopic evaluation was performed 8 varices were ligated. Bleeding from esophageal varices is the most serious and potentially fatal complication of portal hypertension. The rise of portal pressure over 12 mm Hg is necessary for the development of varices. There is not a good correlation between the degree of portal hypertension and the risk of variceal bleeding. However¸ positive correlation between the height of intravariceal pressure and the risk of variceal bleeding exists. Large varices and varices with red spots indicate higher intravariceal pressure. About 30% of the patients may die during the first episode of variceal bleeding. In those who survive¸ rebleeding occurs in 60% of cases with mortality rate exceeding 30%.
Video Endoscopic Sequence 24 of 41.
Another image and video clip of the previously ligated varix (statust post banding).
Video Endoscopic Sequence 25 of 41.
Patient was found the larynx with ictericia due to his cirrotic condition.
Video Endoscopic Sequence 26 of 41.
The next day, 8 varices were banding, the image and the video display a esophageal varix that has been ligated.
Patients who have had one variceal bleed are at high risk of rebleeding. Since its introduction, endoscopic variceal banding has been shown to be superior to needle sclerotherapy.
Video Endoscopic Sequence 27 of 41.
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.
Banding ligation was first reported in humans in 1989 and represents an important development in the endoscopic treatment of varices. It consists of the placement of rubber O-rings on variceal columns, which are sucked into a hollow cylinder attached to the tip of the endoscope. In the acute situation, hemostasis is achieved by physical constriction of the varix at or near the bleeding site, thus interrupting blood flow. In the following days, ischemic necrosis of mucosa and submucosa develops, followed by granulation tissue formation and sloughing of the O-rings and of the necrotic tissue, which leave shallow mucosal ulcerations. Complete reepithelialization takes place in 14-21 days, with full-thickness replacement of the vascular structures with maturing scar tissue.
Video Endoscopic Sequence 28 of 41.
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.
Video Endoscopic Sequence 29 of 41.
This Process is continued until all the bands are deployed. Repeat banding is performed.
Video Endoscopic Sequence 30 of 41.
This image and video display multiple varices that have been ligated.
Video Endoscopic Sequence 31 of 41.
Some more ligated varices.
More bands have been placed on the varices, resulting in spherical blebs. Note the colored elastic bands strangulating each varix at the base.
Video Endoscopic Sequence 32 of 41.
For more endoscopic details download the video clip by clicking on the endoscopic image.
Video Endoscopic Sequence 33 of 41.
The image and the video display gastric cardias in retroflexed maneuver, two varices has been ligated and they become to be necrotic.
Video Endoscopic Sequence 34 of 41.
The video displays multiple varices that have been banding
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.
VideoEndoscopic Sequence 35 of 41.
Seven days after banding a new endoscopy was performed the image and the video clip exhibit the post banding status. All varices that were ligated are in necrotic stage.
VideoEndoscopic Sequence 36 of 41.
One week after endoscopic variceal ligation (EVL). The varices are still strangulated by the elastic O- rings and become necrotic.
VideoEndoscopic Sequence 37 of 41.
Band-ligation may not be a permanent solution since varices can recur after initial eradication, requiring continued surveillance.
Video Endoscopic Sequence 38 of 41.
Based on the results of long-term follow-up of endoscopic variceal ligation, although the percentage of variceal recurrence was high, endoscopic ligation achieved variceal obliteration faster and in fewer treatment sessions. Furthermore, endoscopic variceal ligation had a lower rate of rebleeding and of development of fundal gastric varices, but high portal hypertensive gastropathy.
VideoEndoscopic Sequence 39 of 41.
More images and video clips of this endoscopic sequence.
Video Endoscopic Sequence 40 of 41.
Retroflexed image of the cardias and esophagus the status post banding is observed.
Video Endoscopic Sequence 41 of 41.
Almost all varices of the cardias have been ligated and are in necrotic stage. The risk of re-bleeding has been diminished.
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.
Video Endoscopic Sequence 2 of 10.
Large esophageal varices are seen.
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.
Video Endoscopic Sequence 4 of 10.
Varices with Banding Therapy
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.
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.
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.
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.
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.
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.