ENDOSCOPIC VARICEAL LIGATION IN NAGPUR

Endoscopic variceal ligation is a test which allows the doctor to look directly at the esophageal varices and ligate them to prevent bleeding. Diagnostic endoscopic variceal ligation is recommended for esophageal varices in cirrhotic patients, history of variceal bleeding and as a preventive test for high-risk patients. In order to do the test, an endoscope is carefully passed through the mouth into the esophagus. The endoscope is a long flexible tube, about the thickness of your index finger, with a bright light at its tip. The video camera on the endoscope transmits images of the esophageal lining to a monitor allowing the physician to examine the esophagus checking for varices or abnormalities. If necessary, varices can be ligated through the scope during endoscopic variceal ligation to prevent bleeding. Tissue samples (biopsies) can be taken during the procedure as well.

Diagnosis

Endoscopic variceal ligation can help doctors diagnose the reasons for

• Portal hypertension from cirrhosis

• Esophageal varices on imaging

• History of variceal bleeding

• Hematemesis or vomiting blood

• Melena or black tarry stools

• To evaluate abnormalities in the esophagus in other imaging like ultrasound and CT scan

• Unexplained anemia and blood loss

• Diagnosis and surveillance of variceal recurrence

Endoscopic variceal ligation can also detect the size, location and bleeding status of varices. The procedure is used to look for early signs of variceal disease in cirrhotic patients. The doctor can also take samples from abnormal-looking tissues during the procedure. The procedure, called a biopsy, allows the doctor to later look at the tissue with a microscope for signs of disease.

Endoscopic ultrasound: High frequency ultrasound is applied with endoscopy that will help to assess variceal size, blood flow and predict bleeding risk especially in high-risk patients with large varices.

Doppler endosonography: is a modality when applied with endoscopic variceal ligation can help to assess portal vein flow and differentiate true varices from other esophageal lesions so that therapeutic yield is high.

Treatment

Endoscopic variceal ligation can help doctors with the following issues

• Prevention of first variceal bleed in high-risk patients

• Treatment of active variceal bleeding (emergency)

• Prevention of variceal rebleeding after initial bleeding episode

• Eradication of esophageal varices completely

• Control of bleeding from ruptured varices

• Reduction of portal pressure gradient

• Palliative treatment for bleeding varices (alternative to surgery or transjugular intrahepatic portosystemic shunt)

• Prevention of recurrent hemorrhage and mortality in cirrhotic patients

Interventions

Variceal ligation: elastic bands are placed around varices to cause thrombosis

Endoscopic band ligation (EBL): band applied for the eradication of esophageal varices

Repeat banding: multiple sessions performed to achieve complete variceal eradication

Hemostatic injection: epinephrine or other agents injected for hemostasis if active bleeding present

Sclerotherapy combination: combined ligation and sclerotherapy for difficult varices

Variceal monitoring: follow-up endoscopy performed to assess banding success and variceal healing

Prophylactic ligation: preventive banding performed in high-risk patients without prior bleeding

Post-ligation ulcer management: ulcers developing at banding sites are monitored and treated if bleeding occurs

Preventive

Variceal bleeding surveillance: esophageal varices in cirrhotic patients are on the rise in Asian countries. Surveillance is recommended in average and high-risk patients to detect varices in the early stage which may help in endoscopic prevention avoiding surgery.

Surveillance of patients with decompensated cirrhosis: Patients with advanced cirrhosis and portal hypertension are prone to develop variceal bleeding which can be prevented by endoscopic variceal ligation combined with repeat sessions.

Early detection and ligation of large varices followed by monitoring: Early detection and ligation of large or high-risk varices prevents initial variceal bleeding and reduces mortality significantly.

Primary prophylaxis in high-risk patients: Patients with newly diagnosed varices at high risk for bleeding can undergo primary prophylactic ligation to prevent first variceal hemorrhage.