Download PDF
CC BY-NC-ND 4.0 · Journal of Digestive Endoscopy 2019; 10(04): 213-218
DOI: 10.1055/s-0040-1709085
Original Article

Management of Acute Variceal Bleed by Esophageal Variceal Ligation in an Unconventional Position—An Urban-Center Insight

Umesh Jalihal
1   Karnataka Gastro Center, Bangalore, India
,
Prithvipriyadarshini Shivalingaiah
2   Al Zahra Hospital Sharjah, Sharjah, United Arab Emirates
,
Abhijith Bale 
1   Karnataka Gastro Center, Bangalore, India
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

Background Acute variceal bleed is a fatal complication in patients with liver cirrhosis, and it is important to achieve hemostasis at the earliest. Endoscopic variceal ligation (EVL) is a preferred modality in controlling variceal bleed. The blood pool in esophagus and oozing of blood from varices cause hindrance for variceal ligation leading to failure of therapy. In sitting position, it is hoped that visualization of esophagus may be better. With this background, EVL of patients in sitting position was done and results were analyzed.

Methods Cirrhotics presenting with hematemesis and/or melena were included in the study. Clinical and endoscopic parameters were assessed. Among them, patients having hypotension and hepatic encephalopathy were excluded. Initial endoscopic assessment was done in left lateral position. In case of obscured visualization of esophagus due to flooding, if time taken to achieve hemostasis > 5 minutes, position was changed to sitting from left lateral decubitus. Patients with isolated gastric variceal and ulcer bleed were further excluded.

Results Among 78 acute bleed patients selected, 41fulfilled the inclusion criteria for the study. During endoscopy, in 20 patients, EVL was done in left lateral decubitus position with head end elevation. Twenty-one patients were shifted from conventional left lateral position to sitting posture. Study revealed that patients undergoing EVL in sitting position had better visibility aiding the procedure and no aspiration during the procedure. There was no difference in the left lateral with head raised or without it. Duration of EVL was comparable to that of nonbleeders and additional sclerotherapy was not required in any case in both the groups. Following the procedure, patients were observed for 5 days. There was no failure of therapy which was analyzed according to Baveno VI consensus. However, there was delayed complication in one case due to sepsis and metabolic acidosis causing death.

Conclusion This study suggests, in acute variceal bleed cases, EVL in sitting position aids in better visibility and helps in achieving hemostasis early with least complications.

Keywords

acute variceal bleed - endoscopic variceal ligation - cirrhosis - endoscopy


Publication History

Article published online:
04 May 2020

© .

Thieme Medical and Scientific Publishers Private Ltd.
A-12, Second Floor, Sector -2, NOIDA -201301, India

 

  • References

  • 1 Gado AS, Ebeid BA, Abdelmohsen AM, Axon AT. Clinical outcome of acute upper gastrointestinal hemorrhage among patients admitted to a government hospital in Egypt. Saudi J Gastroenterol 2012; 18 (01) 34-39
    CrossrefPubMedSearch in Google Scholar
  • 2 de Franchis R. Baveno V Faculty. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010; 53 (04) 762-768
    CrossrefPubMedSearch in Google Scholar
  • 3 Dai C, Liu WX, Jiang M, Sun MJ. Endoscopic variceal ligation compared with endoscopic injection sclerotherapy for treatment of esophageal variceal hemorrhage: a meta-analysis. World J Gastroenterol 2015; 21 (08) 2534-2541
    CrossrefPubMedSearch in Google Scholar
  • 4 de Franchis R, Abraldes JG, Bajaj J. et al. Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63 (03) 743-752
    CrossrefPubMedSearch in Google Scholar
  • 5 Sarin SK, Kumar A, Angus PW. et al. Asian Pacific Association for the Study of the Liver (APASL) Working Party on Portal Hypertension. Diagnosis and management of acute variceal bleeding: Asian Pacific Association for Study of the Liver recommendations. Hepatol Int 2011; 5 (02) 607-624
    CrossrefPubMedSearch in Google Scholar
  • 6 D’Amico G, De Franchis R. Cooperative Study Group. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology 2003; 38 (03) 599-612
    PubMedSearch in Google Scholar
  • 7 Terés J, Bordas JM, Bru C, Diaz F, Bruguera M, Rodes J. Upper gastrointestinal bleeding in cirrhosis: clinical and endoscopic correlations. Gut 1976; 17 (01) 37-40
    CrossrefPubMedSearch in Google Scholar
  • 8 Brocchi E, Caletti G, Brambilla G. et al. North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med 1988; 319 (15) 983-989
    CrossrefPubMedSearch in Google Scholar
  • 9 Cheung J, Soo I, Bastiampillai R, Zhu Q, Ma M. Urgent vs. non-urgent endoscopy in stable acute variceal bleeding. Am J Gastroenterol 2009; 104 (05) 1125-1129
    CrossrefPubMedSearch in Google Scholar
  • 10 Hsu YC, Chen CC, Wang HP. Endoscopy timing in acute variceal hemorrhage: perhaps not the sooner the better, but delay not justified. Am J Gastroenterol 2009; 104 (10) 2629-2630, author reply 2630–2631
    CrossrefPubMedSearch in Google Scholar
  • 11 Toubia N, Sanyal AJ. Portal hypertension and variceal hemorrhage. Med Clin North Am 2008; 92 (03) 551-574, viii
    CrossrefPubMedSearch in Google Scholar
  • 12 Bonanno FG. Hemorrhagic shock: the “physiology approach”.. J Emerg Trauma Shock 2012; 5 (04) 285-295
    CrossrefPubMedSearch in Google Scholar