Ligation of esophageal varices

 Esophageal varices are veins abnormally enlarged or dilated, located within the internal portion of the esophagus. Normally, blood circulating through these veins flows to the liver. The enlargement is a consequence of an unhealthy liver causing resistance to normal flow of blood through it. Esophageal varices come with an increased risk of rupture and subsequent hemorrhage that occurs when the pressure within the varicose veins exceeds the resistance of the walls.

The hemorrhage is generally abundant and presents a grave complication, resulting in death in 20% of the cases. Fortunately, not all patients with esophageal varices present bleeding.

Who is at risk of bleeding from esophageal varices?

The risk of hemorrhage increases with the size of the enlarged veins, with increased blood pressure and with thinning vein walls. The possibility of bleeding is heightened in patients with greater degree of liver disease, usually as a result of increased tension of the portal vein. 

What is the best treatment for hemorrhage of esophageal varices?

The most effective treatment to stop gastric hemorrhage due to esophageal varices is ligation with rubber bands. The objective of the treatment is to stop the bleeding, prevent future bleeding by eradicating the varicose veins, and avoiding complications.

How is the ligation performed?

The procedure is performed by placing a plastic barrel on the tip of the endoscope that acts as an applicator for the rubber bands. Once the esophageal varices are located, they are aspirated into the plastic barrel and the rubber band is released in order to trap the vein. The ligated vein is strangulated by the rubber band, making an obstruction to the flow of blood that results in fibrosis or hardening of the area. This obstruction breaks off 3-7 after the procedure, with only a small wound remaining that heals within 15 days.

The ligation of esophageal varices can be performed in cases with or without active bleeding.

Varices with active bleeding: if the location of the bleeding is identified, it must be ligated directly. If finding the location is impossible, then the varices farthest from the general bleeding area are ligated in order to continue approaching the bleeding site. 

Varices without active bleeding: when there is no active bleeding, the procedure begins by ligating the larger varicose veins away in the section of the esophagus closest to the stomach, continuing towards the upper sections.

During each session an average of 5 to 10 rubber bands are placed until all the varices are eradicated. Following the procedure, the patient must adhere to a liquid diet and the prescribed medications. The ligation session can be repeated every 7-14 days.