Endoscopic Variceal Ligation

Vilas R. Patwardhan, MD

Elliot B. Tapper, MD

Acute variceal hemorrhage (AVH) is a devastating complication of cirrhosis and portal hypertension.¹,² The expected overall 6-week mortality associated with AVH is 17.7% (95% CI 14.4% to 21.7%), but it should approach 0% in patients with Child A who receives optimal care.³ A key target for practice improvement is the provision of a high-quality endoscopic procedure. Esophageal band ligation is the first-line therapy for AVH.⁴ However, in many (>10%) cases, patients presenting with AVH do not receive any endoscopic therapy.³ While technical factors and bleeding severity may alter our ability to attain endoscopic hemostasis, operator comfort with endoscopic devices and their indications is essential to improve the outcomes associated with AVH.⁵ Band ligation is also an effective therapy for the primary (and secondary) prophylaxis of variceal hemorrhage. This chapter reviews this technique in depth.

PREPARATION

Acute bleeding

1. Obtain adequate intravenous (IV) access and start fluid resuscitation if indicated.
2. Bolus IV octreotide 50 mcg followed by infusion at 50 mcg/h.
3. Start intravenous antibiotics (first-line therapy is 1 g of ceftriaxone daily).
4. Consider erythromycin 125 mg IV x1 to facilitate gastric emptying of blood.
5. The patient’s blood should be typed and crossed by the blood bank.
6. If hemodynamically stable, the patient should be NPO for 6 hours prior to the examination.
7. Obtain informed, written consent from the patient or a close relative.
8. If hematemesis, delirium, hemodynamic instability, request/arrange endotracheal intubation.
9. If not intubated, administer a topical anesthetic for pharyngeal anesthesia.
10. Obtain medications for sedation (e.g., midazolam and fentanyl). For patients at risk for sedation tolerance, i.e., alcohol consumption, chronic narcotics, or benzodiazepines, consider propofol-based sedation.
11. In the setting of primary or secondary prophylaxis, there is no role for resuscitation, octreotide, antibiotics, type/cross, or routine endotracheal intubation.

EQUIPMENT

1. Upper endoscope. Make sure the ligator device is compatible with the outer diameter and accessory channel length of the endoscope
2. Gloves, safety goggles, or mask with visor, and gown
3. Lubricant
4. 50-mL syringe with Luer-lock tip and sterile saline or water for washing
5. 6- or 7-multiband ligator. Examples include:
- a. Saeed 6 Shooter Multi-Band Ligator (Cook, Bloomington, IN)
- b. (Latex-Free) Speedband Superview Super-7 Band Ligator (Boston Scientific, Natick, MA)
- c. UltraView Multiple Band Ligator (Bard, Covington, GA)
6. As a backup for episodes of band failure: Sodium morrhuate (5%) or sodium tetradecyl (1% or 3%) for injection sclerotherapy