What is endoscopic variceal ligation? Treatment possibilities

What is endoscopic variceal ligation used for?

Endoscopic variceal ligation (EVL) is a minimally invasive procedure used to treat varices, which are abnormally enlarged veins that can occur in the esophagus or stomach.

Varices are a common complication of cirrhosis and other liver diseases that affect blood flow, causing blood to back up into smaller veins. Over time, these veins can become weak and dilated, posing a significant risk of rupture and life-threatening bleeding.

The primary goal of EVL procedure is to control or prevent bleeding from esophageal varices. It works by using an endoscope with a special device at the tip to place small rubber bands around the varices. The bands constrict the veins, causing them to shrink and eventually die off, reducing the risk of hemorrhage (bleeding).

Indications and contraindications of EVL treatment

Endoscopic variceal ligation is an effective procedure for managing esophageal varices, but it is not suitable for every patient.

Indications

• Emergency banding is used to stop active bleeding from ruptured esophageal veins.
• Preventive banding is done to avoid future bleeding or to prevent it from happening for the first time. However, it is not recommended for patients using beta-blockers, those who can’t take them, or if there are large varices at risk of bursting.

Contraindications

• Cardiovascular collapse, shortness of breath.
• Torn bowel, tear in the esophagus, or infection in the abdomen.
• Liver coma.
• Enlarged veins in the stomach.
• Neck spine injuries.
• Lack of consent from parents or legal guardians.
• Relative contraindications: Patients who had recent digestive surgery (within 1 month), or have a blocked intestine. Patients with blood clotting disorders (INR > 2), low platelet count (< 50 G/l) are also not recommended.

How endoscopic variceal ligation is performed

Before the procedure begins, the doctor will administer general anesthesia through an endotracheal tube to reduce the risk of aspiration. The doctor then performs an endoscopy for upper gastrointestinal to assess the severity of esophageal varices, check for any ruptured veins, and identify any other sources of bleeding.

An endoscope is inserted through the patient’s mouth and advanced into the esophagus. A device that holds rubber bands is then inserted to ligate the dilated varices, preventing further bleeding.

Then, the endoscope, equipped with a banding gun, is positioned near the varices. The varices are gently suctioned into a plastic loop, and a rubber band is deployed to securely close them. The doctor continues the process by locating additional varices and applying bands as needed.

The effectiveness of the esophageal banding procedure is evaluated after two weeks. If any varices are still enlarged or at risk of bleeding, further banding may be performed.

Notes before and after EVL procedure

To ensure a successful and safe esophageal banding procedure, you should prepare properly as the following notes:

Before EVL procedure

• Inform your doctor about any heart or blood disorders, allergies (if any) and medications you are taking, especially blood thinners or anticoagulants. These may need to be adjusted or temporarily stopped before the procedure to reduce the risk of bleeding.
• You will be asked to fast for at least 6 – 8 hours before the procedure. This ensures that your stomach is empty, which is essential for the safety of the procedure and the effectiveness of the ligation.
• Depending on your condition, your doctor may order certain tests, such as blood tests or imaging studies, to assess your liver function and the extent of your varices.

After EVl procedure

• Some possible complications during or after EVL include chest pain, difficulty swallowing, nausea, vomiting, bleeding (such as vomiting blood or having black stools), and infection at the banding site.
• Because of the anesthesia, patients should avoid driving or operating machinery for at least 24 hours after the endoscopic therapy. Patients should also rest for 24 hours and eat only soft, liquid foods during that time.

Endoscopic variceal ligation effectively controls bleeding in esophageal varices, offering a safer, minimally invasive option. With proper indications, it enhances treatment outcomes. Therefore, you should always consult a healthcare provider to evaluate if EVL is the right solution for your condition.