Overview
Definition:
Endoscopic Variceal Ligation (EVL) is a minimally invasive endoscopic procedure used to treat or prevent bleeding from esophageal varices, which are enlarged veins in the esophagus typically caused by portal hypertension, often secondary to liver cirrhosis
The procedure involves using a ligating device to place rubber bands around the varices, causing them to thrombose and eventually slough off.
Epidemiology:
Esophageal varices affect approximately 30-50% of patients with cirrhosis
The risk of variceal bleeding is significant, with an annual incidence of 5-15% and a mortality rate of up to 50% in the event of bleeding
EVL is a cornerstone therapy for both acute variceal bleeding and secondary prophylaxis.
Clinical Significance:
Effective peri-operative care for EVL is crucial for minimizing complications, ensuring successful hemostasis, and reducing the risk of re-bleeding
This involves careful patient selection, meticulous pre-procedure preparation, skilled execution of the ligation, and vigilant post-procedure monitoring and management
Proper care directly impacts patient outcomes and reduces hospital stay.
Indications
Primary Prophylaxis:
Prevention of first variceal bleed in patients with medium to large varices (≥5mm) or red wale marks, or Child-Pugh C cirrhosis.
Secondary Prophylaxis:
Prevention of re-bleeding in patients who have previously bled from esophageal varices.
Acute Variceal Hemorrhage:
Therapeutic intervention for active bleeding from esophageal varices, often in conjunction with medical therapy.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination, including assessment of bleeding risk, comorbidities (cardiac, pulmonary, renal), and hepatic function (Child-Pugh score, MELD score).
Laboratory Investigations:
Complete blood count (CBC), coagulation profile (PT/INR, aPTT), liver function tests (LFTs), renal function tests (RFTs), electrolytes, and blood group and cross-match for potential transfusion.
Medications:
Discontinuation of anticoagulants and antiplatelet agents as per protocol
Prophylactic antibiotics (e.g., ceftriaxone, ciprofloxacin) are often administered to reduce the risk of infection, particularly in patients with advanced cirrhosis
Beta-blockers and nitrates for portal hypertension may be continued or adjusted.
Endoscopic Evaluation:
Confirmation of varices, assessment of size, presence of red signs, and identification of bleeding stigmata
Rule out other sources of gastrointestinal bleeding.
Procedure Steps
Endoscope Insertion:
A high-resolution endoscope is inserted into the esophagus under conscious sedation or general anesthesia.
Variceal Identification:
The endoscopist identifies the varices targeted for ligation, typically starting from the gastroesophageal junction and moving proximally.
Ligation Technique:
A special ligating device attached to the endoscope delivers a rubber band around the base of the varix
Multiple bands are placed, usually encircling the varix in a stepwise fashion.
Hemostasis Confirmation:
After ligation, the site is inspected for immediate hemostasis
If bleeding persists, additional bands may be placed, or alternative methods considered.
Postoperative Care
Immediate Monitoring:
Close monitoring of vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) for hemodynamic stability
Assessment for signs of bleeding (hematemesis, melena, hypotension).
Pain Management:
Management of post-ligation discomfort or dysphagia, usually with oral analgesics
Severe pain may indicate complications.
Hydration And Nutrition:
Intravenous fluids may be initiated
Patients are typically kept NPO (nil per os) for a few hours post-procedure, then advanced to clear liquids and a soft diet as tolerated
Strict adherence to dietary recommendations is crucial.
Medications:
Prophylactic antibiotics are continued as per protocol
Beta-blockers and nitrates, if previously used, are usually resumed once hemodynamically stable
Proton pump inhibitors (PPIs) are typically prescribed to reduce gastric acidity and promote healing of the ulcerated sites after band sloughing.
Discharge Planning:
Discharge is usually considered once the patient is hemodynamically stable, tolerating oral intake, and with minimal pain
Patients are educated on warning signs of complications and advised on follow-up appointments.
Complications
Early Complications:
Bleeding (immediate, delayed), perforation of the esophagus or stomach, aspiration pneumonia, post-ligation fever, chest pain, aspiration, laryngeal spasm, and pain
Immediate bleeding may occur during or shortly after the procedure.
Late Complications:
Delayed bleeding (most common complication, occurring 5-10 days post-ligation due to sloughing of the varix and band), esophageal strictures, dysphagia, and ulcer formation at the ligation sites
Variceal recurrence or development of new varices in untreated areas.
Prevention Strategies:
Meticulous technique during ligation to avoid over-ligation or placement too deep into the esophageal wall
Adequate bowel preparation and prophylactic antibiotics reduce infection risk
Careful patient selection and monitoring are key
Timely recognition and management of bleeding, including repeat endoscopy if necessary.
Key Points
Exam Focus:
Understand the indications for EVL (primary/secondary prophylaxis, acute bleeding)
Differentiate early vs
late complications
Recognize the role of prophylactic antibiotics and PPIs
Know the management of re-bleeding post-EVL.
Clinical Pearls:
Always confirm varices with endoscopy before proceeding to ligation
Start ligation from distal to proximal to avoid missing varices
Observe for immediate hemostasis
Counsel patients on dietary restrictions and warning signs of bleeding.
Common Mistakes:
Failure to consider other sources of bleeding
Inadequate prophylactic antibiotic coverage
Over-ligation causing perforation
Not recognizing delayed bleeding as a common and significant complication
Premature discontinuation of PPIs.