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Endoscopic Band Ligationand Esophageal Stents for

Acute Variceal Bleeding

Q2 Q3Q6

Andrés Cárdenas, MD, MMSca,*, Alejandro Fernández-Simon, MDa,Angels Escorcellb

Q4 Q5

KEYWORDS

� Cirrhosis � Gastrointestinal bleeding � Esophageal varices� Endoscopic band ligation � Esophageal stents � TIPS � Portal hypertension� Acute variceal bleeding

KEY POINTS

� Acute variceal bleeding (AVB) is one of the most serious and feared complications of pa-tients with portal hypertension.

� The management of AVB includes a stepped care approach aimed at resuscitation,restrictive transfusion policy, antibiotic prophylaxis, pharmacologic therapy with vasocon-strictors, and endoscopic therapy.

� The most accepted endoscopic method for treating bleeding varices is endoscopic bandligation, which is effective in approximately 90% of patients. Endoscopic sclerotherapymay be used if band ligation is not possible.

� Esophageal stents that cause tamponade of the esophagus are safer and more effectiveas a rescue therapy for AVB than balloon tamponade with Sengstaken Blakemore tubes.

Q9

Video of Endoscopic band ligation technique accompanies this article at http://www.liver.theclinics.com/

Acute variceal bleeding (AVB) is a dreaded complication in patients with portal hyper-tension, and the first episode in a patient with cirrhosis constitutes a significant mile-stone in the progression of the hepatic disease with important implications inprognosis. Mortality rates due to AVB have decreased in the past 30 years, from60% to 15% to 20% at 6 weeks, thanks to improvements in general management,medical treatment, and endoscopic therapy.1 However, there is still a significant

Disclosure: None. Q8a GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, Universityof Barcelona, Barcelona, Spain; b Liver Unit, Institut de Malalties Digestives i Metaboliques,Hospital Clinic, University of Barcelona, Barcelona, Spain Q7

* Corresponding author. Institut de Malalties Digestives i Metaboliques, Hospital Clinic, Univer-sity of Barcelona, Villarroel 170, Esc 3-2, 08036 Barcelona, Spain.E-mail addresses: acardena@clinic.ub.es; acv69@hotmail.com

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Clin Liver Dis - (2014) -–-http://dx.doi.org/10.1016/j.cld.2014.07.003 liver.theclinics.com1089-3261/14/$ – see front matter � 2014 Published by Elsevier Inc.

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recurrence rate and that is why after an episode of AVB patients need secondary pro-phylaxis. Endoscopy by means of using endoscopic band ligation (EBL) plays a keyrole in the management of AVB. Current available methods, combined with vasoactivedrugs, allow for the control of bleeding in approximately 90% of cases within the firstdays of the index bleed.2,3 In cases in which AVB cannot be controlled with endos-copy, balloon tamponade of the esophagus may be required; however, there aresignificant complications with this method. The recent introduction of fully coveredself-expandable metallic stents for AVB is useful in those cases in which balloon tam-ponade is considered, as it is more effective and safer for the temporary control ofbleeding. This article reviews the current management of AVB with particularemphasis on EBL and esophageal stents.

NATURAL HISTORY/DIAGNOSIS

Esophageal varices are present in nearly 30% to 40% of patients with compensatedcirrhosis and in 60% to 80% of those with decompensated cirrhosis.4 They initiallydevelop as small varices that gradually dilate at a rate of 5% per year. Varicealbleeding usually occurs late in the natural history of portal hypertension, and for vari-ces to bleed, portal pressure as measured by the hepatic venous pressure gradient(HVPG) must rise above 12 mm Hg.3,5 Certain characteristics, such as the severityof liver disease, the size of the varix, and the presence of red wale marks (especiallyon thin areas of the variceal wall), place the varices at risk of bleeding, which can occurwith an incidence of 4% to 15% per year.4,6,7 Because patients with cirrhosis with anepisode of upper gastrointestinal bleeding will have varices as the cause in 80% ofcases, bleeding in this setting should be presumed to be of variceal origin.8 Thegold standard for diagnosis of AVB is gastroscopy, which may show active bleedingor oozing from a varix (present in nearly 10%–20% of patients) (Fig. 1), signs of arecent hemostasis white nipple or adherent clot on a varix, or blood in the stomachand/or presence of varices with no other explainable sources of bleeding. Earlyrebleeding rates within the first 48 to 72 hours after the index bleed can be high(30%–40%) if patients are not properly treated.9–11 After 6 weeks, the risk of furtherbleeding is similar to that before the index bleed.11,12 Mortality rates from an episode

Fig. 1. Endoscopic view of an actively bleeding (spurting) esophageal varix in a patient withcirrhosis.

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of variceal bleeding have significantly decreased in the past 3 decades, from 42% inthe 1980s11 to the current rates of 15% to 20%.13–17 This is largely because of theimplementation of standardized guidelines, advances in critical care, better pharma-cologic and endoscopic therapies, use of transjugular intrahepatic portosystemicshunts (TIPS), restrictive transfusion policies, and use of prophylactic antibiotics forbacterial infections. Approximately one-third of the deaths are a direct consequenceof bleeding, whereas the remaining are related to liver failure, infections, and renalfailure.8,18

GENERAL MANAGEMENT

The current recommendations for the general management of patients with anepisode of AVB have been reviewed elsewhere.19 In short, the most important aspectis providing adequate resuscitation (ie, treatment of hypovolemia), avoiding aspirationby protecting the airway and intubation in selected cases, preventing bacterial infec-tions, and stopping the hemorrhage with the use of vasoconstrictors and endoscopictherapy. Intubation always should be considered in patients with hepatic encephalop-athy and actively vomiting blood.20,21 Volume resuscitation with saline or other ex-panders should aim to keep systolic blood pressure between 90 and 100 mm Hg,which can help avoid shock and renal failure.22 Overexpansion may induce reboundincreases in portal pressure and facilitate rebleeding; therefore, a delicate fluid bal-ance is needed in these cases and adequate monitoring in the intensive care unit ishelpful. Red blood cell transfusion should aim for a hemoglobin level of 7 g/dL, exceptin patients with shock, ongoing bleeding, or ischemic heart disease.23 A trial of arestrictive transfusion policy in which patients were transfused if hemoglobin levelsdropped to lower than 7 g/dL (compared with transfusion if hemoglobin <9 g/dL)showed better survival in patients with cirrhosis (Child-Pugh A or B) transfused onlyif hemoglobin levels were lower than 7 g/dL.23 There are no data to support the routineuse of fresh frozen plasma to improve the elevated international normalized ratio in pa-tients with cirrhosis unless they are anticoagulated with warfarin or heparin or otheranticoagulants. Platelets should be transfused if they are below 50,000/mL.24 Bacterialinfections can occur in the setting of AVB, and thus all patients should receive antibi-otics. This measure decreases the risk of infection and rebleeding and improves sur-vival.25–28 In most cases, either norfloxacin 400 mg orally, twice a day for 7 days orintravenous ceftriaxone 1–2 g per day should be given. Intravenous antibiotics arepreferred in those patients with hypovolemic shock and advanced cirrhosis.29 Therapid implementation of vasoconstrictors and performance of endoscopy should beinstituted within the first 12 hours of admission.30 This interval can be shortened to6 hours in those actively vomiting blood once they are stabilized in a monitored unit.Finally, it is important to consider if the patient is a candidate for TIPS, as the earlyplacement of TIPS (within 72 hours) for patients with AVB with Child-Pugh B activelybleeding or C cirrhosis (<13 points) is associated with a significant reduction inrebleeding and mortality and thus should be considered in such cases.31

HEMOSTATIC THERAPIESSplanchnic Vasoconstrictors

There are 2 types of vasoconstrictors used in patients with AVB; the most commonlyused are terlipressin (vasopressin analogue) and somatostatin and its analogue(octreotide). These drugs with specific splanchnic vasoconstrictor activity play afundamental role in the management of AVB and need to be administered as soonas possible and before endoscopy. The early use of vasoconstrictors in most cases

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can initially arrest bleeding, which translates into better visualization at endoscopy.These drugs also reduce rebleeding and improve survival among patients withcirrhosis and AVB.32–36 The available vasoconstrictors and their doses are shown inTable 1. A detailed analysis of the role of vasoconstrictors in AVB is out of the scopeof this review and is detailed elsewhere.36

Endoscopic Therapy

Endoscopy is one of the cornerstones of the management of AVB because it confirmsthe diagnosis and allows specific therapy during the same session. An importantconsideration before considering endoscopy is choosing the type of sedation forthe procedure, as patients need to be fully sedated for the procedure to be successful.We recommend intravenous sedation with propofol, if possible, as it is safe and bettertolerated than benzodiazepines (midazolam) plus an opiates (meperidine or fentanyl),which can trigger episodes of minimal hepatic encephalopathy.37–39 Endoscopic ther-apies for varices are effective because they cause obliteration of the varix. The 2 endo-scopic methods available for AVB are endoscopic sclerotherapy (ES) and EBL. ESconsists of the injection of a sclerosing agent (sodium morrhuate 5%, ethanolamineoleate 5%, or polidocanol 1%–2%) into the variceal lumen or adjacent to it. Thiscauses inflammation and thrombosis, creating a scar over the site of the varix.Although it is easy to perform (only need an injection catheter and the sclerosant) thereare significant side effects related to the procedure. There are a number of local andsystemic complications, which include esophageal ulcers, strictures, substernal chestpain, fever, dysphagia, and even the development of pleural effusions.40,41 Anotherproblem is the risk of bacteremia, which may arise in up to 30% to 55% of casesand can predispose to spontaneous bacterial peritonitis or distal abscesses.42,43

Other rare complications include perforation, mediastinitis, pericarditis, chylothorax,and esophageal motility disorders.40,41,44,45 Compared with EBL of varices, ES forAVB is associated with higher rebleeding rates and more side effects, such as ulcersand strictures.46 Clinical trials have shown that EBL is better than ES for all major out-comes, including initial control of bleeding, recurrent bleeding, side effects, time tovariceal eradication, and even survival.47,48

EBL

EBL was introduced an alternative with fewer complications to ES for the treatment ofesophageal varices. The concept of using EBL for esophageal varices arose in the1980s.49 Given the anatomy and zones of venous return in the gastroesophageal junc-tion Stiegmann and colleagues50 sought out a means of blocking this drainage. Theveins in the palisade zone, which extend proximal to the cardias into the lower esoph-agus, are the veins most likely to bleed because this is an area between the portal andsystemic circulation with no perforating veins from the submucosa allowing fordrainage or decompression to periesophageal veins. Thus, a way of “safely” of

Table 1Vasoconstrictors used in acute variceal bleeding

Drug Dose

Terlipressin Intravenous bolus 2 mg/4 h for 24–48 h then 1 mg/4 h

Somatostatin Intravenous bolus 250 mg followed by infusion of 250–500 mg/h

Octreotide Intravenous bolus of 50–100 mg followed by infusion of 50 mg/h

All drugs are administered for a minimum of 2 days and may be prolonged for up to 5 days.

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obliterating these vessels was that of placing rubber bands on the varices in the distalesophagus similar to what surgeons use for treating hemorrhoids. The rest is history,and currently EBL is considered the endoscopic treatment of choice for AVB. In brief,EBL consists of the placement of several elastic bands (range between 4–10) on thevarices so as to occlude the varix and cause thrombosis. The technique is shown inVideo 1. Ligation of the varix and surrounding mucosa eventually leads necrosis ofthe mucosa. The bands fall off within 5 to 7 days, leaving a shallow ulcer that healsand subsequently scars. After the index treatment of an episode of AVB, scheduledrepeat sessions need to be performed at 3-week to 4-week intervals to completelyobliterate the varices and reduce the risk of rebleeding.51

There are several commercially availablemultiband devices. In Europe and the UnitedStates themost common are the SaeedMultiple Ligator (Wilson-CookMedical, Inc) andthe Speedband (Microvasive Boston Scientific Corporation). They have between 4 and10 preloaded bands. We prefer to always start the procedure with a 6-band or 7-banddevice. This allows for enough bands to be placed in a single session without havingto repeatedly intubate thepatientwith thegastroscope.Band ligators haveoneprinciple:placement of elastic bands on a varix after it is sucked into a clear plastic cylinderattached to the tip of the endoscope (Fig. 2). After the indexdiagnostic endoscopy isper-formed in a patientwith AVBand the suspected varix is identified, the endoscope iswith-drawnand the ligationdevice is loaded. Thedeviceneeds tobe firmly attached to shaft ofthe scope near the knobs (Fig. 3). At this point, the patient needs to be reintubated andthis sometimes can be difficult because the cap of the ligator makes the distal tip of thescope thicker and there is limited vision. It is better to perform a slight flexion of the pa-tient’s neck and then push very gently with slight torque to the left or right, always withdirect visualization of the pharynx.Once the esophagus is intubated, the knob on the de-vice needs to be on “forward-only”mode. After the varix is identified, the tip of the scopeis pushed toward it and continuous suction applied so the mucosa of the varix fills thecap and causes a “red-out” sign; at this point, the band can be fired and a click mustbe felt (see Fig. 3, Video 1). Afterward, the scope should not be advanced distally soas to prevent dislodgement of band. This is the reason why ligation should alwayscommence in the most distal portion of the esophagus near the gastroesophageal(GE) junction. Bands are applied in a spiral pattern, progressing up the esophagus untilall major columns of varices of the lower third of the esophagus (no more than 8–10 cmabove theGE junction) are banded. If there is a limited viewbecauseofongoingbleeding,an option is to aggressively flush with water, perform suction, and start placing bands at

Fig. 2. Endoscopic view of large varices (left) and endoscopic view of successfully placedbands in the distal esophagus (right).

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Fig. 3. (A) Band ligator placed on the shaft of the endoscope, the knob is attached to theworking channel. (B) The proximal end of the endoscope has a cap with premounted bandsthat allows for suction of the varix (in this case a glove is used). (C) Once the varix is suc-tioned into the cap, the band is fired and the varix is ligated.

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the GE junction. This reduces the heavy bleeding and further bands can be firedafterward.The procedure is not exempt from complications either, and these include transient

dysphagia and chest pain, which respond well to liquid analgesics (ie, acetamino-phen), as well as an oral suspension of antacids. A liquid diet should be started thesame day and soft foods the next day. Shallow ulcers at the site of bands are frequentand can bleed in up to 4% of cases.52 The use of a proton pump inhibitor (ie, panto-prazole 40 mg per day for 10 days) decreases the size of ulcers but does not preventthem from bleeding.53 Severe and rare complications, such as massive bleeding fromulcers or rarely from variceal rupture, esophageal perforation, esophageal strictures,or altered esophageal motility, may occur with EBL.54 If a patient bleeds due to an ul-cer after EBL, ES may be performed. Another option is applying Hemospray (a hemo-static powder) to the bleeding site. This powder, which is used for nonvaricealgastrointestinal bleeding, seems to be promising as a hemostatic technique for pa-tients with portal gastropathy, variceal bleeding, and bleeding after EBL ulcers.55–57

EBL is highly effective in the control of AVB, with an immediate efficacy in 90% ofcases.2 Two randomized controlled trials that compared EBL and ES in AVB47,48

have clearly shown that treatment with EBL along with vasoconstrictors is associatedwith higher efficacy, safety, and improved mortality than ES and vasoconstrictors. Inaddition, in 8 other trials, these 2modalities also were compared in AVB and in the pre-vention of rebleeding. A meta-analysis of the 10 trials shows that EBL is better than ESin the initial control of bleeding, and is associated with fewer adverse events andimproved mortality (Fig. 4).58 Therefore, EBL is considered the endoscopic therapy

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Esophageal Stents for Acute Variceal Bleeding

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of choice in AVB. Although EBL is preferred over ES for an episode of AVB, in thesetting of active hemorrhage or torrential bleeding, EBL may be sometimes difficultto perform because of lack of visibility. Therefore, both techniques are reasonable op-tions in the setting of AVB.

ESOPHAGEAL STENTS

Balloon tamponade of the esophagus is used in patients in whom endoscopic therapycannot stop the bleeding or in those patients with a known history of esophageal vari-ces in whom such profuse bleeding and hemodynamic status precludes an upperendoscopy. Current guidelines recommend using balloon tamponade only in massivebleeding, as a temporary “bridge” until definitive treatment can be instituted (for amaximum of 24 hours) in an intensive care unit.22,59 Esophageal balloon tamponade,which is typically performed with a Sengstaken-Blakemore tube, causes hemostasisby direct compression of the bleeding varices. If placed properly, tamponade mayprovide initial control of bleeding in up to 85% of cases, but recurrence is observedin 50% of the patients after deflation of the balloon.60 The most common complica-tions include aspiration pneumonia and esophageal perforation, which may occur in30% of patients, with a mortality rate of 5%mainly due to perforation.60 The incidenceof complications increases with the duration of tamponade and when tubes areinserted by inexperienced staff. Therefore, tamponade should be performed only byskilled and experienced personnel in intensive care facilities and with special cautionin patients with respiratory failure or cardiac arrhythmias. Because of the high risk ofaspiration pneumonia, tamponade should be preceded by prophylactic orotrachealintubation in most patients.An alternative to balloon tamponade is placing fully covered self-expandable metal

stents that act with a tamponade mechanism on the esophagus.61 This certainly repre-sents a promising therapeutic alternative to balloon tamponade. The main advantagesinclude fewer side effects, ability to maintain enteral feeding, and the possibility to leavethe stent in place for 1 week, which allows for stabilization of the patient so as to planbridge therapies, such as TIPS. The SX-Ella Danis stent (135 � 25 mm; ELLA-CS, Hra-dec Kralove, Czech Republic) is a removable, fully covered, and self-expanding nitinolmetal stent with atraumatic edges specifically designed for AVB (Fig. 5). It comes in aready-to-use procedure pack that contains all items necessary for its placement. In

Fig. 5. A fully covered self-expandable esophageal stent can be placed in the esophagus as arescue therapy in patients in whom variceal bleeding cannot be controlled by endoscopictherapy plus vasoactive drugs. The stent (SX-Ella Danis) is 135 mm long � 25 mm wideand has 2 threads in the distal and proximal end that allows the stent to be pulledendoscopically.

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Fig. 6. (A) Once the stent is advanced into the stomach, a distal balloon at the proximal endis inflated with a syringe. (B) Then the stent is pulled back until it anchors in the cardias andlower esophagus and then deployed and the introducer is withdrawn.

Esophageal Stents for Acute Variceal Bleeding 9

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addition, it has radiopaque markers at both ends and midportion for monitoring withplain chest radiographs. The stent can be deployed in the lower esophagus withoutradiological or endoscopic assistance; however, in some cases, a prior endoscopy isuseful as a means to leave a rigid guidewire in the stomach, which later aids in placing

Table 2Case series reporting the efficacy of esophageal stents as a rescue therapy for the treatmentof acute variceal bleeding Q15

No.Patients

SEMSDeployed,%

InitialHemostasis,%

Rebleed,%

Migration,%

MortalityFollow-Up, d

Hubmannet al,66

2006

15 100 100 0 13 20% 60 d

Zehetneret al,67

2008

34 100 100 0 18 29% 60 d

Wrightet al,65

2010

10 90 70 14 NR 50% 42 d

Decheneet al,63

2012

8 100 100 38 0 75% 60 d

Holsteret al,68

2013

5 100 100 20 20 40% 180 d

Zakariaet al,69

2013

16 94 88 0 38 25% NR

Fierzet al,62

2013

7 100 89 0 0 77% 42 d

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507

the premounted stent. The procedure is relatively easy to perform but basic training isneeded to understand how it is placed. Once the stent has been advanced to the stom-ach, a distal balloon at the proximal end is inflated with a syringe and then the stent ispulled back until it anchors in the cardias and lower esophagus. This then allows itsdeployment, thus no fluoroscopy is needed (Fig. 6). The stent can be removed 7 dayslater endoscopically using an overtube system (Extractor for SX-ELLA stent Danis)without causing trauma to the esophagus. Several case series have demonstrated itsafety and efficacy in AVB (Table 2).62–69 In most published cases, the stents havebeen successfully deployed inmore than 90%of patients. The results on immediate he-mostasis range between 70% and 100%. In most cases, patients can be offered abridge therapy, such as TIPS or repeat endoscopic treatment with EBL or ES. A draw-back of using the stent is migration, which can occur in 20% of cases.61,65,66

We recently performed a multicenter randomized controlled trial (published in ab-stract form) comparing esophageal stenting versus balloon tamponade in 28 patientswith AVB refractory to medical and endoscopic treatment and/or with massivebleeding precluding endoscopy.70 Fifteen patients were randomized to balloon tam-ponade and 13 to stent placement. Primary outcome measure was success of ther-apy, defined as survival at day 15 with control of bleeding and without seriousadverse events. Our results showed that esophageal stents were more effectivethan balloon tamponade for the temporary control of bleeding in those patients withabsence of rebleeding at 15 days in 77% in the stent group versus 47% in the balloontamponade group. Side effects occurred in 8% of patients in the stent group versus52% in the balloon tamponade group. There were no differences in survival, but the

Suspected variceal bleeding

Vasoactive drugs

Antibiotics, volume restitution

Endoscopy – Confirms diagnosis and can implement EBLa

control

Drugs 2-5 days

Start secondary prophylaxis

mild

Repeat endoscopic Tx

severe

TIPSfailure

failure

bConsider temporary measures

Fig. 7. Recommended algorithm for the treatment of an episode of acute variceal bleeding.a Placement of TIPS (within 72 hours) for patients AVB with Child B actively bleeding or Ccirrhosis (<13 points) is associated with a significant reduction in rebleeding and mortalityand can be considered in such cases. b Temporary measures include placement of an esoph-ageal stent or balloon tamponade. Esophageal stents are preferred, as they are safer andmore effective. The use of the balloon is associated with potentially lethal complications,such as aspiration and perforation of the esophagus. Tx, treatment.

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primary end point of the study was on efficacy and safety and not survival. These bet-ter results were due to both a greater hemostatic effect and a lower rate of seriousadverse events, especially aspiration pneumonia, with the use of esophageal stents.70

These results favor the use of esophageal stents in patients with uncontrolled AVB,although further controlled studies are needed.

Failure to Control Bleeding

Approximately 10% to 15% of patients do not respond to the previously mentionedtherapies. In such cases, if the patient is stable, a second therapeutic endoscopymay be performed. However, if this is unsuccessful or there is massive bleeding,the patient should be considered for other treatments, such as TIPS. This topic is dis-cussed in detail in the article by Garcia-Pagan and colleagues, elsewhere in this issue.

Q12

SUMMARY

AVB is a dreaded complication of patients with cirrhosis and portal hypertension(Fig. 7). Initial management should focus on resuscitation with adequate volumereplacement, careful blood transfusions to keep hemoglobin levels at 7 g/dL, antibioticprophylaxis, and endotracheal intubation in selected cases. Standard of care man-dates for early administration of vasoactive drugs and EBL within the first 12 hoursof the index bleed. Patients who fail combined pharmacologic and endoscopic ther-apy may require temporary placement of balloon tamponade or esophageal stents un-til definitive treatment (preferably TIPS) can be instituted. Given the available data,esophageal stents in this setting are preferred. Patients who fail the previouslymentioned therapies should undergo an evaluation for TIPS.

SUPPLEMENTARY DATA

Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.cld.2014.07.003.

Q13

REFERENCES

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2. Qureshi W, Adler DG, Davila R, et al. ASGE Guideline: the role of endoscopyin the management of variceal hemorrhage, updated July 2005. GastrointestEndosc 2005;62:651–5. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16246673. Accessed February 11, 2014.

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4. De Franchis R, Primignani M. Natural history of portal hypertension in patientswith cirrhosis. Clin Liver Dis 2001;5:645–63. Available at: http://www.ncbi.nlm.nih.gov/pubmed/11565135. Accessed February 27, 2014.

5. Merli M, Nicolini G, Angeloni S, et al. Incidence and natural history of small esoph-ageal varices in cirrhotic patients. J Hepatol 2003;38:266–72. Available at: http://www.ncbi.nlm.nih.gov/pubmed/12586291. Accessed February 27, 2014.

6. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver andesophageal varices. A prospective multicenter study. N Engl J Med 1988;319:

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CLD715_proof ■ 14 August 2014 ■ 3:37 pm

Our reference: CLD 715 P-authorquery-v9

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ANDR�ES C�ARDENAS, MD, MMSc, AGAF, GI/Endoscopy Unit, Institut de Malalties Digestives i

Metaboliques, Hospital Clinic, University of Barcelona, Barcelona, Spain

ALEJANDRO FERN�ANDEZ-SIMON, MD, GI/Endoscopy Unit, Institut de Malalties Digestives i

Metaboliques, Hospital Clinic, University of Barcelona, Barcelona, Spain

ANGELS ESCORCELL, Liver Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic,

University of Barcelona, Barcelona, Spain

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PubMed: Patients with portal hypertension and esophageal varices are at risk of bleeding due to

a progressive increase in portal pressure that may rupture the variceal wall. Appropriate treatment with

initial general measures, such as resuscitation, a restrictive transfusion policy, antibiotic prophylaxis,

pharmacologic therapy with vasoconstrictors, and endoscopic therapy with endoscopic band ligation are

mandatory. However, 10% to 15% of patients fail initial endoscopic therapy and thus rescue therapies are

needed. This article reviews the current endoscopic strategies with band ligation and esophageal stents for

patients with acute variceal bleeding.

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