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Endoscopic variceal ligation (EVL) is the standard-of-care therapy for treating and preventing recurrence of acute esophageal variceal hemorrhage.1 EVL can also be used to prevent a patient's first variceal bleeding episode, particularly in patients who have medium or large varices showing high-risk signs for bleeding or patients who are intolerant to β-blocker therapy.1–3 EVL has supplanted the use of endoscopic sclerotherapy (EST), as EVL has a lower overall complication rate and equal or better efficacy for controlling acute bleeding and lowering rebleeding rates.4–11 Complications of EST include stricture formation, ulceration of esophageal mucosa, rebleeding, hematoma formation, perforation, spontaneous bacterial peritonitis, and pulmonary infections.3,6–9,11,12 Complications of EVL, on the other hand, are generally benign.4,6–9,11 However, dysphagia following EVL has often been reported in the literature.6,10,11,13 Complete esophageal obstruction causing dysphagia has been reported only once previously in the literature.14 We report the second case of complete esophageal obstruction following EVL. Our patient was managed conservatively and experienced a good outcome.
A 67-year-old woman with Child-Pugh class A cirrhosis secondary to primary biliary cirrhosis (PBC) presented to our endoscopy suite to undergo her second esophago-gastroduodenoscopy (EGD) for band ligation of known esophageal varices. The patient had been diagnosed with PBC 3 years previously. Four months prior to presentation, she had been referred to our institution for consideration of orthotopic liver transplantation. At that time, she had never been screened for esophageal varices. An EGD performed shortly thereafter at an outside institution detected grade 2–3 varices. Treatment with a nonselective β-blocker was initiated; however, the patient was intolerant to this drug due to her history of asthma. Therefore, she began a series of EVLs for primary prophylaxis against variceal hemorrhage. These procedures revealed 4 columns of grade 3 varices with high-risk signs for bleeding (ie, red wales and cherry red spots). During her first EVL procedure, a total of 5 bands were successfully placed without adverse outcomes.
At the time of the patient's second EGD for EVL, grade 3 varices were seen and again showed high-risk features. Three bands were successfully placed in the distal esophagus. In the recovery suite following the procedure, the patient complained of severe chest pain (giving it a score of 10 on a scale from 1 to 10) and was unresponsive to both intravenous meperidine and a solution of aluminum hydroxide, magnesium hydroxide, simethicone, and viscous lidocaine. Within minutes of drinking the solution, the patient vomited white liquid with no evidence of blood. She was admitted to our hospital for further evaluation and treatment.
Upon admission to our hospital, the patient was afebrile with normal vital signs (a heart rate of 60 beats per minute, respiratory rate of 18 breaths per minute, blood pressure of 110/56 mmHg, and oxygen saturation rate of 100% on room air). Physical examination revealed an elderly female in no acute distress, and cardiopulmonary examination was unremarkable. Abdominal examination was notable for mild epigastric tenderness to palpation but no rebound or guarding. The patient's bowel sounds were normoactive, and the remainder of her examination was normal. Results from laboratory tests taken upon admission were normal, except for slightly elevated levels of total bilirubin, alkaline phosphatase, and aspartate aminotransferase, all of which were stable. An acute abdominal series was within normal limits.
On the second day of hospitalization, the patient's pain was slightly better; however, she was still unable to tolerate liquids. She was also expectorating all of her oral secretions into an emesis basin and had slight odynophagia. A gastrografin swallow study was performed, showing complete obstruction at the level of the distal esophagus (Figure 1). No contrast or air was noted in the stomach. Due to the obstruction, the patient was started on partial parenteral nutrition.
Fortunately, on the seventh day after her EGD, the patient began to tolerate liquids. She was subsequently discharged the following day.
EVL was first introduced in 1986.4 Prior to EVL's inception, EST was used to control active variceal bleeding and prevent recurrent hemorrhage. However, due to its induction of tissue injury, EST is associated with complications in nearly 40% of patients.4–6 Complications of EST include stricture formation, ulceration of esophageal mucosa, rebleeding, hematoma formation, perforation, spontaneous bacterial peritonitis, and pulmonary infections.4,6–9,11,12 Stricture formation rates are as high as 33%, and dysphagia occurs in 7—30% of patients who undergo EST.9,11,12
EVL has consistently demonstrated equal or better efficacy compared to EST in terms of controlling acute bleeding varices and lowering rebleeding rates and mortality.4,7,8,9,11 As these benefits have been achieved with fewer complications, EVL has become the standard-of-care treatment for esophageal varices.1,4–10 To perform EVL, the clinician places a small, elastic O-ring over a small area of esophageal mucosa and submucosa.4,7,15 The ensnared tissue is strangulated, leading to ischemia and, eventually, sloughing, fibrosis, and variceal obliteration.7,15 Given that this technique is purely mechanical, transmural inflammation is not invoked, and systemic complications are not seen.4,10 Complications commonly described after EVL include stricture formation, ulcers, ulcer bleeding, pneumonia, and spontaneous bacterial peritonitis.4,6–9,11 Ulcer formation is nearly universal, documented in 94% of patients on follow-up EGD.9,11,15 Stricture formation occurs in 0% of patients in some reported series (n=64 and n=38), and an early meta-analysis comparing EVL and EST revealed a stricture odds ratio of 0.10 in favor of EVL.4,7,9 The occurrence of transient dysphagia (lasting 24–72 hours) is variable; this complication has been reported in anywhere from 0% to 75% of patients in various published case series.11,13 Engorged banded varices are the presumed cause of this phenomenon.6 Another unique complication described by Berner and associates is altered lower esophageal sphincter relaxation following EVL.10 However, significant differences in acid reflux and esophageal motility were not demonstrated.10
To date, there has been only 1 case of esophageal obstruction as a complication of EVL that has been reported in the literature.14 A 58-year-old man with cirrhosis secondary to hepatitis C virus infection who had a history of esophageal variceal bleeding had undergone 2 sessions of EST. He subsequently underwent 2 sessions of EVL 3 weeks apart. At the time of the first EVL session, grade 3 varices were noted, and 4 bands were placed without difficulty. The second EVL session again revealed grade 3 varices, for which an additional 4 bands were placed without complications. After endoscopy, the patient resumed a normal diet and experienced chest discomfort and sialorrhea. An emergent upper endoscopy revealed food stuck in the esophagus above the banded varices. On inspection, the newly banded varices had completely obstructed the esophageal lumen. The authors postulated that the newly banded varices had swollen, thereby completely occluding the lumen.
Three pathophysiologic mechanisms have been proposed to explain the occurrence of dysphagia following EVL. The most commonly proposed mechanism is stricture formation, which typically presents as late dysphagia, allowing time for fibrosis progression and stricture formation.6,7,13,15 Dysphagia that presents soon after EVL may be secondary to transient alterations in esophageal motility.10,13,15 Finally, as in this case report, complete esophageal obstruction can occur.14
We postulate that complete obstruction of the esophagus is an exceedingly rare complication of EVL that occurs due to several interrelated factors, not simply engorged varices that fill the esophageal lumen. Clearly, the size of the banded varix contributes to this phenomenon. However, the size of the banding cap limits the volume of each individual varix that can be banded.15 Therefore, the size of the banded varix cannot be the only factor; otherwise, this complication would be more common. In this case report and in the first reported case of complete esophageal obstruction due to EVL, both patients underwent 2 EVL sessions; in the first case, the patient also underwent 2 prior EST sessions. Prior to undergoing these procedures, the esophageal mucosa may already have abnormalities, such as undetected strictures from prior therapy or an unrelated Schatzki ring. If a varix is banded proximally to 1 of these areas, it is possible that the peristaltic action of the esophagus could propagate the banded varix into the strictured segment, creating a ball-valve effect. The effects of this scenario would be similar to those resulting from a food impaction caused by a Schatzki ring. The stalk created by a banded varix would prevent further distal propagation of the varix until it sloughs off 1–2 weeks after placement of the band.
Complete esophageal obstruction has been described in the literature only once before. In this case report, we present the second such case. Immediate complaints of dysphagia after banding—along with the presence of sialorrhea or the inability to tolerate liquids—should suggest the possibility of obstruction. Obstruction can be documented by a contrast swallow study. If the patient has not eaten recently (ie, there is no chance of a food impaction), we do not recommend performing a repeat endoscopy, as it could dislodge a band and cause bleeding. Conservative measures such as intravenous fluids and parenteral nutrition may be needed. With time, the varix should slough, and dysphagia should be relieved.