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Gandhi M, Chela HK, Daglilar E, Hammoud G. Mushroom Sign: Complete Esophageal Obstruction After Esophageal Variceal Band Ligation With Successful Removal of Variceal Band. ACG Case Rep J 2023; 10:e01093. [PMID: 37441621 PMCID: PMC10335816 DOI: 10.14309/crj.0000000000001093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/05/2023] [Indexed: 07/15/2023] Open
Abstract
Esophageal varices due to portal hypertension are treated with endoscopic variceal band ligation (EVBL), a minimally invasive procedure with potential complications, such as pain, bleeding, and stricture formation. Rarely, complete esophageal obstruction can occur secondary to edema of the mucosa. Most cases can be managed conservatively, but intervention is necessary for severe symptoms with a risk for aspiration and airway compromise. Since EVBL is such a common procedure, it is important for clinicians to be aware of this rare but severe complication. An 80-year-old woman presented with severe dysphagia and chest discomfort after a recent EVBL. Esophagogastroduodenoscopy revealed esophageal mucosal edema and complete obstruction of the esophageal lumen. The band was removed with a loop cutter with subsequent balloon dilation to relieve the obstruction.
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Affiliation(s)
- Mustafa Gandhi
- Department of Medicine, University of Missouri, Columbia, MO
| | - Harleen Kaur Chela
- Department of Gastroenterology and Hepatology, Charleston Area Medical Center, West Virginia University School of Medicine, Charleston, WV
| | - Ebubekir Daglilar
- Department of Gastroenterology and Hepatology, Charleston Area Medical Center, West Virginia University School of Medicine, Charleston, WV
| | - Ghassan Hammoud
- Department of Medicine, University of Missouri, Columbia, MO
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2
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Sobotka LA, Ramsey ML, Wellner M, Kelly SG. Rare cause of dysphagia after esophageal variceal banding: A case report. World J Gastrointest Endosc 2019; 11:292-297. [PMID: 31040890 PMCID: PMC6475704 DOI: 10.4253/wjge.v11.i4.292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/14/2019] [Accepted: 03/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Esophageal varices are a result of progressive liver disease and portal hypertension. Treatment can be performed with band ligation versus non-selective beta blockers depending on the size of varices, ability to tolerate medications and history of variceal bleeding. Band ligation is an effective intervention with rare but serious complications including bleeding, ulcers and rarely obstruction. Few cases of esophageal obstruction and necrosis caused by banding have been reported, each with varied management from conservative treatment to band removal.
CASE SUMMARY An 89 years old woman with a past medical history of nonalcoholic steatohepatitis cirrhosis presented to the hospital with an inability to swallow one day after screening esophagogastroduodenoscopy where band ligation of esophageal varices was performed for primary prophylaxis. The patient was not able to tolerate her oral secretions. Initial blood work revealed a Model of End Organ Liver Disease score of 7. She was treated with sublingual nitroglycerin for esophageal spasm, a known complication after esophageal banding. When she failed to improve, esophagogastroduodenoscopy was performed and revealed the mucosa surrounding the banded varix was necrosed and blocking the lumen of the esophagus. The band was purposefully dislodged, revealing distal ulceration and stricturing. Within 72 h after band removal, she was tolerating an oral diet. Endoscopy performed 2 wk later revealed an intrinsic stenosis, measuring 8 mm in diameter by 1 cm in length, which was dilated.
CONCLUSION Esophageal obstruction is a complication of variceal banding that should be considered in patients with inability to tolerate oral diet after banding.
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Affiliation(s)
- Lindsay A Sobotka
- Department of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Mitchell L Ramsey
- Department of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Michael Wellner
- Department of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Sean G Kelly
- Department of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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3
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Sobotka LA, Ramsey M, Wellner M, Kelly SG. Rare cause of dysphagia after esophageal variceal banding: A case report. World J Gastrointest Endosc 2019. [DOI: 10.4253/wjge.v11.i4.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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4
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Jalil AAA, Hammoud G, Ibdah JA, Samiullah S. Removal of Esophageal Variceal Bands to Salvage Complete Esophageal Obstruction. Clin Endosc 2018; 51:491-494. [PMID: 30130842 PMCID: PMC6182280 DOI: 10.5946/ce.2018.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 04/10/2018] [Indexed: 11/21/2022] Open
Abstract
Esophageal varices develop in almost half of the patients with cirrhosis, and variceal hemorrhage constitutes an ominous sign with an increased risk of mortality. Variceal banding is considered an effective and mostly safe measure for primary and secondary prophylaxis. Although adverse events related to banding including dysphagia, stricture formation, bleeding, and ligation-induced ulcers have been described, complete esophageal obstruction is rare, with only 10 reported cases in the literature. Among those cases, 6 were managed conservatively; 1 patient had esophageal intraluminal dissection from an attempt to remove the bands using biopsy forceps but ultimately recovered with conservative management. Three patients developed strictures following removal of the bands, requiring repeated sessions of dilation therapy. We report on a patient who developed absolute dysphagia and complete esophageal obstruction after variceal banding. We successfully used the endoloop cutter hook to release the bands intact and restore luminal integrity.
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Affiliation(s)
- Ala' A Abdel Jalil
- Division of Gastroenterology & Hepatology, University of Missouri-Columbia, Columbia, MO, USA
| | - Ghassan Hammoud
- Division of Gastroenterology & Hepatology, University of Missouri-Columbia, Columbia, MO, USA
| | - Jamal A Ibdah
- Division of Gastroenterology & Hepatology, University of Missouri-Columbia, Columbia, MO, USA
| | - Sami Samiullah
- Division of Gastroenterology & Hepatology, University of Missouri-Columbia, Columbia, MO, USA
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5
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Aziz M, Floyd B, Esfandyari T. A Rare Case of Complete Esophageal Obstruction Following Esophageal Variceal Band Ligation (EVBL) for Esophageal Varices Performed by Esophagogastroduodenoscopy (EGD). AMERICAN JOURNAL OF CASE REPORTS 2018; 19:545-548. [PMID: 29739920 PMCID: PMC5967289 DOI: 10.12659/ajcr.908232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Esophageal variceal band ligation (EVBL) performed by esophagogastroduodenoscopy (EGD) is a routinely performed procedure for the treatment of esophageal varices that is undertaken to control bleeding and prevent further complications. This report is of a case of a rare complication of complete esophageal obstruction following EVBL. CASE REPORT A 69-year-old woman underwent EVBL for esophageal varices. She subsequently presented with complete obstruction of the esophageal lumen with ulceration, which was seen on repeat EGD. Following conservative management, EGD demonstrated scarring around the ulcerated region and a patent esophagus. CONCLUSIONS This case report serves to remind physicians of the potential complications that may arise with the use of EVBL treatment for bleeding esophageal varices and to consider the use of a loop cutter, to grasp and remove the esophageal band to improve patient recovery.
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Affiliation(s)
- Muhammad Aziz
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Beth Floyd
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Tuba Esfandyari
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
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6
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Kubovy J, Boswell TD, Vautier G, Arnold MM. Complete esophageal obstruction following endoscopic variceal ligation: a case report and literature review. Clin Exp Gastroenterol 2018; 11:165-168. [PMID: 29692620 PMCID: PMC5901155 DOI: 10.2147/ceg.s161772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Endoscopic variceal ligation (EVL) is an important treatment modality in managing complications of portal hypertension. Since its advent 30 years ago, the procedural complications have decreased significantly, especially when compared with variceal sclerotherapy. With the current widespread use of EVL, rare complications are now becoming increasingly recognized. We present a case of complete esophageal obstruction, its management, and clinical course. Our literature review identified only eight reported cases. We compare the varied treatment approaches and outcomes in the cited articles.
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Affiliation(s)
- Jan Kubovy
- Department of Gastroenterology, Hawkes Bay Hospital, Hastings, New Zealand
| | - Tom D Boswell
- Department of Gastroenterology, Hawkes Bay Hospital, Hastings, New Zealand
| | - Guy Vautier
- Department of Gastroenterology, Hawkes Bay Hospital, Hastings, New Zealand
| | - Malcolm M Arnold
- Department of Gastroenterology, Hawkes Bay Hospital, Hastings, New Zealand
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7
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Complete Esophageal Obstruction after Endoscopic Variceal Band Ligation in a Patient with a Sliding Hiatal Hernia. ACG Case Rep J 2017; 4:e8. [PMID: 28144613 PMCID: PMC5247629 DOI: 10.14309/crj.2017.8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 10/07/2016] [Indexed: 12/19/2022] Open
Abstract
Complete esophageal obstruction is a rare complication of endoscopic variceal banding, with only 6 cases in the English literature since the introduction of endoscopic variceal banding in 1986. We report a case of complete esophageal obstruction following esophageal banding due to entrapment of part of a sliding hiatal hernia. To our knowledge, our case is one of few with esophageal obstruction post-banding, and the first associated with a hiatal hernia. We recommend caution when performing esophageal banding on patients with a hiatal hernia.
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8
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Wonaga A, Ozollo-Landa C, Piskorz MM, Waldbaum C, Sordá J. Aphagia following esophageal variceal ligation. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 38:496-8. [PMID: 25182734 DOI: 10.1016/j.gastrohep.2014.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 07/17/2014] [Accepted: 07/20/2014] [Indexed: 01/06/2023]
Affiliation(s)
- Andrés Wonaga
- Division of Gastroenterology, Hospital de Clínicas José de San Martín, Buenos Aires, Argentina.
| | - Carolina Ozollo-Landa
- Division of Gastroenterology, Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - María Marta Piskorz
- Division of Gastroenterology, Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - Carlos Waldbaum
- Division of Gastroenterology, Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - Juan Sordá
- Division of Gastroenterology, Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
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9
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Chahal H, Ahmed A, Sexton C, Bhatia A. Complete esophageal obstruction following endoscopic variceal band ligation. J Community Hosp Intern Med Perspect 2013; 3:20043. [PMID: 23882397 PMCID: PMC3716036 DOI: 10.3402/jchimp.v3i1.20043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 12/19/2012] [Indexed: 12/21/2022] Open
Abstract
Variceal hemorrhage is a potential complication of portal hypertension. Besides medical management, endoscopic variceal band ligation (EVBL) has emerged as a promising prophylactic tool proving to be superior to sclerotherapy. EBVL is a simple procedure associated with minor complications and short recovery time. In this report, we present a case of a rare complication of complete esophageal obstruction following an EVBL procedure. Given the high numbers of such procedures performed, it is imperative that internists and specialists be aware of this unusual complication.
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Affiliation(s)
- Harjit Chahal
- Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD, USA
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10
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Vanbiervliet G, Giudicelli-Bornard S, Piche T, Berthier F, Gelsi E, Filippi J, Anty R, Arab K, Huet PM, Hebuterne X, Tran A. Predictive factors of bleeding related to post-banding ulcer following endoscopic variceal ligation in cirrhotic patients: a case-control study. Aliment Pharmacol Ther 2010; 32:225-32. [PMID: 20412065 DOI: 10.1111/j.1365-2036.2010.04331.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Life-threatening bleeding caused by early spontaneous slippage of rubber bands has been described after variceal ligation in cirrhotic patients. AIM To determine the predictive factors of this complication in cirrhotic patients. METHODS Among 605 patients, 21 patients (mean age 56.6 +/- 13.5 years) developed 23 spontaneous band slippages with bleeding on post banding ulcer, as confirmed by endoscopy. Cirrhosis was alcoholic in 13 patients (62%), post viral hepatitis in three (14%) and from other causes in five (24%). A case-control study was performed comparing 17 from these patients who presented the complication after a first ligation with 84 of the 584 controls who underwent first endoscopic variceal ligation without bleeding complication. RESULTS Bleeding occurred 13.5 days +/- 7.3 (2-29) following ligation. Eleven patients died following the bleeding complication (52%). Using a multivariate analysis, previous upper variceal digestive bleeding [OR 12.07, 95%CI (2.3-63.43)], peptic oesophagitis [OR 8.9, 95%CI (1.65-47.8)], high platelet ratio index (APRI) score [OR 1.54, 95%CI (1.11-2.16)] and low prothrombin index [OR 0.54, 95% CI (0.31-0.94)] were independent predictive factors of bleeding. CONCLUSIONS Bleeding related to post-banding ulcer is a rare, but severe complication. The proposed predictive factors should be looked for and minimized before variceal ligation.
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Affiliation(s)
- G Vanbiervliet
- Faculté de Médecine, Université de Sophia-Antipolis, Nice, F-06107, France.
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11
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Abstract
Gastrointestinal endoscopy is an evolving field kindled by technologic advances, scientific discoveries, and the innovative minds of endoscopists. The development and subsequent applications of overtubes in gastrointestinal endoscopy mirror this larger evolution. In this article, we review the development, applications, and complications associated with overtubes in gastrointestinal endoscopy.
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Affiliation(s)
- Christopher D Wells
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona 85259, USA
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12
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13
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Affiliation(s)
- J. E. J. KRIGE
- Surgical Gastroenterology, Department of Surgery and M. R. C. Liver Research Centre, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - J. F. BOTHA
- Surgical Gastroenterology, Department of Surgery and M. R. C. Liver Research Centre, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - P. C. BORNMAN
- Surgical Gastroenterology, Department of Surgery and M. R. C. Liver Research Centre, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
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14
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Seo YS, Park JJ, Kim JH, Kim JY, Yeon JE, Kim JS, Byun KS, Bak YT. Removal of press-through-packs impacted in the upper esophagus using an overtube. World J Gastroenterol 2006; 12:5909-12. [PMID: 17007065 PMCID: PMC4100680 DOI: 10.3748/wjg.v12.i36.5909] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Foreign bodies in the upper esophagus should be removed as soon as possible to avoid serious complications. However, removals of foreign bodies in the upper esophagus are very difficult, especially if they have sharp edges, such as press-through-packs (PTPs). We experienced four cases of the impacted PTPs in the upper esophagus which was successfully extracted endoscopically with the overtube. Because two edges of PTPs were so firmly impacted in the esophageal wall in all cases, the PTPs were not movable in the upper esophagus. However, after insertion of the overtube, PTPs became movable and were successfully extracted and no serious complications occurred after extraction of PTPs. In one case, insertion of the overtube rapidly expanded the upper esophagus and PTP progressed to the gastric cavity and it could be extracted with the endoscopic protector hood. The endoscopic removal with the overtube was a simple, safe and effective technique for the removal of the impacted PTPs in upper esophagus.
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Affiliation(s)
- Yeon-Seok Seo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Medical Center, Guro Hospital, Gurodong-gil 97, Guro-gu, Seoul, Korea
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15
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Helmy A, Hayes PC. Review article: current endoscopic therapeutic options in the management of variceal bleeding. Aliment Pharmacol Ther 2001; 15:575-94. [PMID: 11328251 DOI: 10.1046/j.1365-2036.2001.00950.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Variceal bleeding is a frequent and life-threatening complication of portal hypertension. The first episode of variceal bleeding is not only associated with a high mortality, but also with a high recurrence rate in those who survive. Therefore, many studies and randomized clinical trials have focused on different therapeutic strategies aiming to prevent the first episode of variceal bleeding (primary prophylaxis), to control haemorrhage during the acute bleeding episode (emergency treatment), and to prevent re-bleeding (secondary prophylaxis). These strategies involve pharmacological, endoscopic, surgical, and interventional radiological modalities. This review concentrates on the clinical aspects of the endoscopic modalities used to treat oesophageal variceal haemorrhage, including variceal injection sclerotherapy, variceal band ligation, and the use of tissue adhesives (glue) and their substitutes. We also draw conclusions from the available literature regarding the use of endoscopic modalities in primary prophylaxis, emergency treatment, and secondary prophylaxis of variceal re-bleeding. The management of gastric varices and variceal bleeding during pregnancy is also addressed.
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Affiliation(s)
- A Helmy
- Liver Unit, Department of Medicine, Royal Infirmary and University of Edinburgh, Edinburgh, Scotland, UK.
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16
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Toyoda H, Fukuda Y, Katano Y, Ebata M, Nagano K, Morita K, Yokozaki S, Takeuchi M, Hayakawa T. Fatal bleeding from a residual vein at the esophageal ulcer base after successful endoscopic variceal ligation. J Clin Gastroenterol 2001; 32:158-60. [PMID: 11205654 DOI: 10.1097/00004836-200102000-00014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Endoscopic variceal band ligation (EVL) is now one of the accepted treatment options for esophageal varices, and the safety of this procedure has been proved. However, we experienced a patient who had a fatal massive bleeding after successful EVL for ruptured esophageal varix. Postmortem study revealed a residual vein at the base of the esophageal ulceration associated with the ligation, which was believed to be the site of the fatal bleeding. His platelet counts and prothrombin time were not very impaired. Our case indicates that fatal massive bleeding can occur in patients after successful EVL without specific risk factors and indicates the importance of the awareness of the possibility of these complications.
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Affiliation(s)
- H Toyoda
- Second Department of Internal Medicine, Nagoya University School of Medicine, Japan
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17
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Abstract
BACKGROUND There is no standardized method for the evacuation of gastric phytobezoars. Prior endoscopic attempts have used injected cellulase and various devices to disrupt bezoars. The efficacy of directed, large-channel suction using an endoscope for the removal of large gastric phytobezoars is the subject of this study. METHODS Three consecutive patients with large gastric bezoars were examined. Phytobezoar removal using a standard endoscope (GIF-100, Olympus) was attempted but unsuccessful. Each phytobezoar was successfully evacuated by directed suction through an endoscope with a large-diameter accessory channel (GIF-XT30, Olympus). Each patient was followed up for bezoar recurrence. RESULTS Rapid, complete bezoar evacuation was achieved at one session in all patients. Aspirated volumes were 500, 700, and 1000 mL. There were no procedure-related complications. CONCLUSIONS Endoscopic suction removal of gastric phytobezoars using a large-channel endoscope is efficacious and safe. Coupling directed endoscopic suction with other endoscopic techniques might be efficacious for removal of more complex bezoars.
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Affiliation(s)
- M E Blam
- Hospital of the University of Pennsylvania, University of Pennsylvania Health System and School of Medicine, Philadelphia, Pennsylvania, USA
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18
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Bohnacker S, Sriram PV, Soehendra N. The role of endoscopic therapy in the treatment of bleeding varices. Best Pract Res Clin Gastroenterol 2000; 14:477-94. [PMID: 10952810 DOI: 10.1053/bega.2000.0092] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The role of endoscopy in bleeding varices is both diagnostic and therapeutic. While sclerotherapy of oesophageal varices remains an established modality, ligation has, in view of its higher safety margin, turned out to be superior in recent years. The excellent initial results of ligation are, however, tainted by a higher recurrence rate in the long term. Since the end-point of treatment is the achievement and maintenance of variceal eradication, the addition of low-dose sclerotherapy following initial eradication by ligation seems to be the optimal method to combine the best of both techniques. In the management of life-threatening bleeding from oesophageal varices and gastric varices, cyanoacrylate remains the only promising non-surgical option. Primary endoscopic prophylaxis is still under evaluation. It is only justified in high-risk patients with large varices bearing red colour signs and in the presence of an intolerance of or contra-indication to propranolol. When indicated, ligation seems to be preferable, and the addition of low-dose sclerotherapy after initial variceal eradication may maintain the benefits accrued in such high-risk patients. The present review examines the available evidence regarding the above issues in the recent literature.
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Affiliation(s)
- S Bohnacker
- Department of Interdisciplinary Endoscopy, University Hospital Eppendorf, Hamburg, Germany
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19
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Cappell MS, Abdullah M. Management of gastrointestinal bleeding induced by gastrointestinal endoscopy. Gastroenterol Clin North Am 2000; 29:125-67, vi-vii. [PMID: 10752020 DOI: 10.1016/s0889-8553(05)70110-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Therapeutic gastrointestinal endoscopy has a much greater risk of inducing gastrointestinal hemorrhage than diagnostic endoscopy. For example, colonoscopic polypectomy has a risk of approximately 1.6% of inducing bleeding, compared with a risk of approximately 0.02% for diagnostic colonoscopy. Higher-risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy, and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage should be immediately treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques.
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Affiliation(s)
- M S Cappell
- Division of Gastroenterology, Maimonides Medical Center, Brooklyn, New York, USA
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20
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Hepworth CC, Burnham WR, Swain CP. Development and application of endoloops for the treatment of bleeding esophageal varices. Gastrointest Endosc 1999; 50:677-84. [PMID: 10536327 DOI: 10.1016/s0016-5107(99)80020-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoloops are detachable nylon snares. The aims of this study were to develop an endoscopic method for repeated delivery of endoloops to arrest variceal bleeding, to compare efficacy of endoloop hemostasis with injection and band ligation in experimental models of bleeding, and to test the reliability and safety of endoloops in a pilot study in patients with varices. METHODS Technical modifications including ridged endcaps and alterations in angulation of endoloops were developed to speed delivery and improve efficacy. Hemostatic efficacy of endoloops was compared with sclerotherapy and band ligation in animal studies before studies in patients. RESULTS Modified endcap and endoloops allowed repeated applications without withdrawal of the endoscope. Right-angled endoloops ensnared more (p < 0.0001) gastric tissue and were more reliable (p < 0.05) than straight endoloops. Injection therapy and prestretched bands appeared ineffective, whereas band ligation was only effective on vessels up to 2 mm in diameter. Only endoloops achieved hemostasis on vessels of 3 to 5 mm (p < 0.05). No significant complications occurred using endoloops in animal (esophagus n = 20, stomach n = 20) or human (n = 11) studies. CONCLUSIONS Endcap and endoloop modifications simplified repeated application to varices. Endoloops were more effective than injection or band ligation in experimental hemostasis and appeared safe and effective in patients.
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Affiliation(s)
- C C Hepworth
- Oldchurch Gastroenterology Department, Romford, Essex, United Kingdom
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21
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Wong SY, Ng FH, Kng C. Esophageal variceal ligation by reloading with inexpensive hemorrhoidal O-ring--is an overtube necessary? J Clin Gastroenterol 1999; 29:158-60. [PMID: 10478877 DOI: 10.1097/00004836-199909000-00011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
The overtube is the major cause for severe complications during endoscopic variceal ligation with a single-shot ligator. This retrospective study was designed to examine the necessity of the placement of an overtube during elective endoscopic variceal ligation. Thirty-one sessions in 18 patients were analyzed. An overtube was inserted using an over-the-scope technique in 11 sessions (group 1) but was omitted in 20 sessions (group II). The complications, technical difficulties, and operating time were analyzed. Child's grading, the size of the esophageal varices, and the number of rubber bands deployed were comparable in both groups. There was a significantly longer operating time (p < 0.01) and more oropharyngeal injury (p = 0.03) in group I than in group II. Mid esophageal injury, which was associated with resistance in withdrawing the gastroscope from the overtube, occurred in 55% of sessions in group I but in 0% of session in group II. In conclusion, the use of an overtube is associated with more complications, and it can be omitted during elective endoscopic variceal ligation.
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Affiliation(s)
- S Y Wong
- Department of Medicine, Ruttonjee Hospital, Hong Kong, China
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22
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Abstract
BACKGROUND For 25 years the optimal management of bleeding oesophageal varices has included endoscopic injection sclerotherapy (EIS) both to arrest bleeding and to prevent rebleeding. However, the recent innovation of endoscopic variceal ligation (EVL) may be a more effective treatment; this paper reviews its efficacy. METHODS All Medline (National Library of Medicine, Washington DC, USA) articles containing the text words 'oesophageal varices', 'sclerotherapy' or 'band ligation' were reviewed. Prospective randomized studies comparing sclerotherapy with band ligation, or combinations thereof, were included. RESULTS After an acute variceal bleed EVL is as effective as EIS for control and eradication of oesophageal varices. Initial control of bleeding is similar, but eradication is achieved in fewer sessions with EVL. EVL is associated with lower rebleeding rates and fewer procedure-related complications; it is also more effective for control of active bleeding at initial endoscopy. Combination therapy (EIS plus EVL) confers no advantage over EVL alone. CONCLUSION EVL is similar to EIS for control of bleeding varices, but the former has less associated morbidity, lower rebleeding rates and achieves more rapid variceal eradication. EVL should be considered the endoscopic treatment of choice in the management of variceal haemorrhage.
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Affiliation(s)
- I S Tait
- Department of Surgery and MRC Liver Research Centre, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
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23
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Levy R, Kaur S, Uzer M. Separation of an overtube from the bite block during band ligation of esophageal varices. Gastrointest Endosc 1997; 46:66-8. [PMID: 9260709 DOI: 10.1016/s0016-5107(97)70213-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- R Levy
- Section of Digestive Diseases, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612-3824, USA
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24
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Abstract
The first use of an overtube to assist endoscopy was described more than 20 years ago. Since then a number of uses of overtubes have been described, but relatively few complications have been reported. We report a case of esophageal perforation caused by overtube insertion during endoscopic band ligation of varices. This case is unique in that the patient presented 13 days after the original procedure, and it is the first reported case of esophageal injury involving the modified Bard overtube. The existing literature involving overtube injury is also reviewed.
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Affiliation(s)
- J P Dinning
- Department of Internal Medicine, University of Arizona Health Sciences Center, Tucson 85724, USA
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25
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Abstract
Endoscopic sclerotherapy has been the mainstay in the management of esophageal variceal bleeding to control acute bleeding and decrease recurrent bleeding. Endoscopic variceal ligation is a new technique that is equally effective in the control of acute bleeding but achieves obliteration of varices in fewer treatment sessions with presumably less cost, results in a lower rebleeding rate, has fewer complications, and is associated with reduced mortality. Combination therapy with both endoscopic variceal ligation and endoscopic sclerotherapy appears to have no clear advantage over variceal ligation alone. On the basis of the results of a number of trials comparing sclerotherapy with band ligation, endoscopic variceal ligation has evolved to be the preferred first line modality for the endoscopic treatment of variceal bleeding.
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Affiliation(s)
- E A Slosberg
- Division of Gastroenterology, Department of Medicine, Stanford University School of Medicine, Stanford, California 94305-5202, USA
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26
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Dennert B, Ramirez FC, Sanowski RA. A prospective evaluation of the endoscopic spectrum of overtube-related esophageal mucosal injury. Gastrointest Endosc 1997; 45:134-7. [PMID: 9040997 DOI: 10.1016/s0016-5107(97)70235-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Placement of an overtube is required for endoscopic variceal ligation. The spectrum of overtube-related esophageal mucosal injury is unknown. We made a prospective comparison of two types of overtubes and a determination of the frequency, severity, and risk factors for overtube-related injury. METHODS Two overtubes (60F, 20 cm, "new" overtube; and 60F, 25 cm, "old" overtube) were used and placed using the bougie-assisted technique. Mucosal integrity was documented before and after variceal ligation. Overtube contact time, bands number, setting (emergent versus elective), type of overtube, degree of coagulopathy, and development of symptoms after variceal ligation were recorded. RESULTS Fifty sessions in 29 patients were analyzed; 24% of sessions were emergent. The old overtube was used in 24 sessions and the new in 26. Mucosal injury occurred in 72% of sessions. Mean overtube contact time was 11.58 +/- 0.97 minutes, the mean number of bands placed per session was 6.4 +/- 0.4, and the mean international normalized ratio was 1.47 +/- 0.06. No risk factors correlated with mucosal injury except for the old overtube, which was associated with tears (p = 0.02). CONCLUSIONS Mucosal injury related to the overtube is frequent but clinically unimportant. Because mucosal tears occurred significantly more often with the old overtube, we suggest that its use should be avoided.
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Affiliation(s)
- B Dennert
- Department of Medicine, Carl T. Hayden VA Medical Center, Phoenix, AZ 85012, USA
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27
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Lo GH, Lai KH, Cheng JS, Hwu JH, Chang CF, Chen SM, Chiang HT. A prospective, randomized trial of sclerotherapy versus ligation in the management of bleeding esophageal varices. Hepatology 1995. [PMID: 7635414 DOI: 10.1002/hep.1840220215] [Citation(s) in RCA: 146] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We conducted a prospective, randomized trial comparing sclerotherapy and ligation in 120 patients with acute bleeding of esophageal varices. All the patients were cirrhotic, 59 received sclerotherapy, and 61 received ligation. Treatment was repeated regularly until the varices were obliterated. The mean follow-up period was 295 +/- 120 days and 310 +/- 105 days for the sclerotherapy and ligation groups, respectively. The control of active bleeding was 12/15 (80%) in the sclerotherapy group and 18/19 (94%) in the ligation group (P = .23). The numbers of treatment sessions required to achieve variceal obliteration were 6.5 +/- 1.2 in the sclerotherapy group and 3.8 +/- 0.4 in the ligation group (P < .001). Recurrent bleeding from the gastrointestinal tract was 51% in the sclerotherapy group compared with 33% in the ligation group (P < .05). Recurrent bleeding from esophageal varices was 36% in the sclerotherapy group and 11% in the ligation group (P < .01). However, bleeding from ectopic varices and congestive gastropathy was less common in the sclerotherapy group (7%) than in the ligation group (18%) (P = .05). Significant complications were encountered in 19% of the sclerotherapy group and in 3.3% of the ligation group (P < .01). Comparison of Kaplan-Meier estimates of time to death of both groups showed a significantly lower mortality in the ligation group (P = .011). Both sclerotherapy and ligation can effectively arrest active bleeding from esophageal varices. However, ligation is more effective than sclerotherapy in decreasing the risk of rebleeding from esophageal varices with fewer complications. Ligation can also achieve obliteration of esophageal varices more rapidly than sclerotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- G H Lo
- Department of Medicine, Veterans General Hospital-Kaohsiung, National Yang-Ming University, Taipei, Taiwan, Republic of China
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28
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Mamel JJ, Weiss D, Pouagare M, Nord HJ. Endoscopic suction removal of food boluses from the upper gastrointestinal tract using Stiegmann-Goff friction-fit adaptor: an improved method for removal of food impactions. Gastrointest Endosc 1995; 41:593-6. [PMID: 7672555 DOI: 10.1016/s0016-5107(95)70197-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- J J Mamel
- Division of Digestive Diseases and Nutrition, University of South Florida, College of Medicine, Tampa 33612, USA
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29
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Affiliation(s)
- R Yang
- Department of Medicine, University of Southern California School of Medicine, Los Angeles 90033, USA
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30
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Chen CY, Lin CY, Chang TT, Shin JS. A simple maneuver for placing an overtube during endoscopic variceal ligation. Gastrointest Endosc 1995; 41:83-4. [PMID: 7698636 DOI: 10.1016/s0016-5107(95)70289-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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