Endoscopic variceal ligation (EVL) was developed in an effort to find an effective means of treating esophageal varices endoscopically with fewer complications than sclerotherapy (ES) [1-4]. The concept was based upon many years of experience treating hemorrhoids with rubber band ligation in patients with and without portal hypertension. EVL works by capturing all or part of a varix resulting in occlusion from thrombosis. The tissue then necroses and sloughs off in a few days to weeks, leaving a superficial mucosal ulceration, which rapidly heals. EVL avoids the use of sclerosant and thus eliminates the deep damage to the esophageal wall that occurs after ES. Collateral vessels near the cardia decrease after EVL, which may be another reason that EVL is effective for preventing further variceal bleeding [5]. Another interesting finding is that during acute variceal bleeding the hepatic venous pressure gradient (which correlates with the risk of variceal bleeding) increases after ES, but not after EVL [6].The first patient was treated with EVL in 1986. Since then, advances in the technique have led to its routine use in the care of patients with esophageal varices. One of the biggest advances was the development of the multiple band ligator (Saeed Six-Shooter and Speedbander), which has simplified and improved the safety of EVL.The technical considerations involved in EVL and the data supporting its technical efficacy will be reviewed here. The role of EVL in the care of patients with varices is discussed separately. (See "Treatment of active variceal hemorrhage"and "Prevention of recurrent variceal hemorrhage in patients with cirrhosis".)TECHNIQUEEndoscopic variceal ligating devices are placed on the tip of standard endoscopes. The device has a soft sheath potion that fits over the tip of the endoscope and a hard plastic portion. There is also a separate hard plastic part over which the bands are stretched and ready to be deployed. Currently available devices are designed for standard and therapeutic sized endoscopes.The procedure begins after a thorough upper endoscopy to identify the esophageal varices that are to be treated. Actively bleeding varices or those with stigmata indicating recent bleeding (such as a fibrin plug or a "red wale" sign) should be primary targets even if they are not located at the gastroesophageal junction (picture 1A-B). There are no absolute restrictions on coagulation parameters that preclude performing EVL, although in patients with active bleeding, attempts should be made to improve the coagulation status [7].

ESOPHAGEAL VARICES The presence of varicose veins in the esophagus constitutes a serious condition which is potentially life-threatening. It is an entity which is readily discovered by Video-endoscopy. Amonst the causes of esophageal varices one must consider liver cirrhosis as the most frequent, but also portal hypertension and thrombosis of the portal or splenic veins can be made responsible in some cases. For this reason a Video-endoscopic procedure should be performed on all patients in which liver cirrhosis is suspected. Although the definite diagnosis of liver cirrhosis can only be made with a liver biopsy, the presence of esophageal varices in itself constitutes an indirect sign of liver cirrhosis with a 95% accuracy. The potentially life-threatening aspect of esophageal varices lies in the danger of their profuse bleeding , considered to be one of the severest hemorrhages of the whole g.i. tract. The ptient presents with bloody vomiting and black stools (melena). If this condition is not treeated promptly hypotension (fall in blood pressure) will set in and patient may succumb.

Esophageal varices are dilated blood vessels within the wall of the esophagus. Patients withcirrhosis develop Portal Hypertension. When Portal Hypertension occurs, blood flow throughthe liver is diminished. Thus, blood flow increases through the microscopic blood vessels withinthe esophageal wall. As this blood flow increases, the blood vessels begin to dilate. Thisdilation can be profound. The original diameter of the blood vessels is measured inmillimeters while the final, fully established, esophageal varix may be 0.5 to 1.0 cm or larger indiameter.Bleeding varices are a life-threatening complication of portal hypertension (increased bloodpressure in the portal vein caused by liver disease). Increased pressure causes the veins toballoon outward. The vessels may rupture, causing vomiting of blood and bloody stools ortarry black stools. If a large volume of blood is lost, signs of shock will develop. Any cause ofchronic liver disease can cause bleeding varices.

A 83 year-old, non-alcoholic female that had an upper gastrointestinal hemorrhage. For more endoscopic details download the video clip by clicking on the image. Esophageal varices are dilated blood vessels within the wall of the esophagus. Patients with cirrhosis develop Portal Hypertension. When Portal Hypertension occurs, blood flow through the liver is diminished. Thus, blood flow increases through the microscopic blood vessels within the esophageal wall. As this blood flow increases, the blood vessels begin to dilate. This dilation can be profound. The original diameter of the blood vessels is measured in millimeters while the final, fully established, esophageal varix may be 0.5 to 1.0 cm or larger in diameter. Bleeding varices are a life-threatening complication of portal hypertension (increased blood pressure in the portal vein caused by liver disease). Increased pressure causes the veins to balloon outward. The vessels may rupture, causing vomiting of blood and bloody stools or tarry black stools. If a large volume of blood is lost, signs of shock will develop. Any cause of chronic liver disease can cause bleeding varices. For more endoscopic details, download the video clip by clicking on the endoscopic image. Wait to be downloaded complete then Press Alt and Enter for full screen.

Acute Variceal BleedEndoscopic Sequence 1 of 10.

Severe upper gastrointestinal hemorrhage due to esophageal varices. 40 year-old, alcoholic male that has been drinking continuously for 3 months a bottle of alcoholic beverage every day, came to emergency room presenting severehematemesis, patient presented Hypovolemic shockhis average of arterial blood pressure was 70/40.Acute bleeding from esophageal varices requires anendoscopic evaluation and aggressive therapeutic intervention. Endoscopy in a patient with massive bleeding demands attention to details. Adequate volume and blood replacement before and during endoscopy is vital, so is protection of the airway in a patient that is liable to aspiration. This may be achieved with endotracheal intubation.

More details download the video clips of this endoscopic sequence.

Endoscopic Sequence 2 of 10.This image displays the exactly site of the bleeding at the cardias, actve variceal bleeding is appreciated. DIAGNOSIS OF THE BLEEDING SOURCE, Endoscopy is an essential step in the diagnosis and treatment of acute variceal bleeding.For more endoscopic details download the video clip by clicking on the endoscopicimage.

Endoscopic Sequence 3 of 10.The image and the video display active variceal bleeding that is appreciated through the banding apparatus.

Endoscopic Sequence 4 of 10.Endoscopic variceal ligation (banding) Endoscopic variceal ligation is based on the widely used technique of rubber-band ligation of hemorrhoids. The esophageal mucosa and the submucosa containing varices are ensnared, causing subsequent strangulation, sloughing,and eventual fibrosis, resulting in obliteration of the varices.Endoscopic ligation requires placement of an opaque cylinder over the end of the endoscope. This decreases the endoscopic field of view and may allow pooling of blood. Thus, in patients with active bleeding, visualization may be impaired more with ligation than with sclerotherapy.Recent trials have demonstrated that ligation and sclerotherapy achieved similar rates of initial hemostasis in patients whose varices were actively bleeding at the time oftreatment. Local complications are less common with ligation compared to sclerotherapy. For example, esophageal strictures were found to be less common with ligationcompared to sclerotherapy. Systemic complications, such as pulmonary infections and bacterial peritonitis, were not significantly different in the 2 groups. However, a trend wasobserved toward a decrease in these 2 complications in patients treated with ligation.

Endoscopic Sequence 5 of 10. The next day, 8 varices were banding, the image and the video display a esofageal varix thathas been ligated.Patients who have had one variceal bleed are at high risk of rebleeding. Since its introduction, endoscopic variceal banding has been shown to be superior to needlesclerotherapy.

Endoscopic Sequence 6 of 10.The image as wellas the video clip displays the cardias with varix ligated.Variceal banding or sclerotherapy. Endoscopic therapy, particularly variceal banding (alsocalled ligation), may be used to treat and prevent variceal bleeding in the esophagus. In thepast, sclerotherapy was the main treatment to stop a first episode of variceal bleeding, but ithas fallen out of favor. Most doctors now prefer variceal banding because it works as well as sclerotherapy to stop bleeding and has fewer complications.

Endoscopic Sequence 7 of 10. More images and videos of same case. Technique uses a device attached to the tip of theendoscope that allows the varix to be suctioned into a banding chamber, whereupon an elastic band is then deployed around the base of the captured varix. After 3 to 7 days the ligated tissue sloughs, leaving a shallow ulceration with scar tissue.

Endoscopic Sequence 8 of 10. Some more ligated varices. More bands have been placed on the varices, resulting inspherical blebs. Note the colored elastic bands strangulating each varix at the base.

Endoscopic Sequence 9 of 10. The video displays multiple varices that have been banding. Mortality due to variceal bleeding secondary to portal hypertension has decreased significantly in the past 2decades. Endoscopic therapy has been the mainstay of treatment for acute variceal bleeding. Variceal banding ligation has superceded injection sclerotherapy as the most popular treatment modality for acute bleeding. Multiple banding ligators are widely used with high success in restoring hemostasis. The combination of banding and sclerotherapy may be useful in preventing the early recurrence of varices and rebleeding after initial obliteration of varices.

Endoscopic Sequence 10 of 10.Seven days after banding a new endoscopy was performed the image and the video exhibit the post banding status All varices are in necrotic stage.

Esophageal Varices. 61 year old female, living in the U.S., who, being a salvadorean national, had come to visit El Salvador on vacation. While still in the airport, patient developed upper g.i. tract hemorrhage and was admitted to the Centro de Emergencias Hospital. Patient had history of liver cirrhosis and was awaiting liver transplant in the U.S The image shows various reddish maculae where it is presumed the hemorrhage startedPatient was initially treated with Minnesota tube and various varices were later on sclerosed. Patient was able to return to the U.S. a few weeks later.

Gastric Varices.The retroflexed endoscopic view shows various nodules at the gastric fundus.Hemorrhage from esophageal varices constitues a real emergency which must be promtly and vigorously treated. Eesophageal tamponade by the implementation of the Senstaken-Blakemore or the Minnesota tube is utilized. Variceal sclerosing is another form of treatment which utilizes the fibre-optic endoscope to inject a special substance into the varicose veins of the esophagus, in order to obliterate (sclerose) them. The endoscope is fitted with a special device known as varices injector, which consists of a special cable, which displays a needle-shaped injector on one end and a syringe adapter on the other (external) end. Another method sometimes used to treat bleeding esophageal varices involves the ligation of the varicose veins by means of special rubber bands. It is a method similar to the one employed in the treatment of rectakl hemorrhoids, and relatively easy to implement.

Sub-epithelial gastric varix. 67 year old female who presented with various esophageal varices. This image is readily confused with a gastric polyp, a fact which one must always bear in mind when planning to perform a polypectomy mainly at the fundus and cardias. When the diagnosis is doubtful, one should resort to the endoscopic ultrasound to differentiate between a gastric polyp and gastric varices