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Complete Esophageal Obstruction Following Endoscopic Variceal Ligation G&H C l i n i C a l C a s e s t u d i e s Complete Esophageal Obstruction Following Endoscopic Variceal Ligation Matthew A. Nikoloff, MD Division of Gastroenterology and Hepatology, The Pennsylvania State Thomas R. Riley, III, MD University Milton S. Hershey Medical Center, Hershey, Pennsylvania Ian R. Schreibman, MD ndoscopic variceal ligation (EVL) is the stan- tion, she had been referred to our institution for consider- dard-of-care therapy for treating and preventing ation of orthotopic liver transplantation. At that time, she recurrence of acute esophageal variceal hemor- had never been screened for esophageal varices. An EGD Erhage.1 EVL can also be used to prevent a patient’s first performed shortly thereafter at an outside institution variceal bleeding episode, particularly in patients who detected grade 2–3 varices. Treatment with a nonselective have medium or large varices showing high-risk signs β-blocker was initiated; however, the patient was intoler- for bleeding or patients who are intolerant to β-blocker ant to this drug due to her history of asthma. Therefore, therapy.1-3 EVL has supplanted the use of endoscopic she began a series of EVLs for primary prophylaxis against sclerotherapy (EST), as EVL has a lower overall com- variceal hemorrhage. These procedures revealed 4 col- plication rate and equal or better efficacy for controlling umns of grade 3 varices with high-risk signs for bleeding acute bleeding and lowering rebleeding rates.4-11 Com- (ie, red wales and cherry red spots). During her first EVL plications of EST include stricture formation, ulceration procedure, a total of 5 bands were successfully placed of esophageal mucosa, rebleeding, hematoma forma- without adverse outcomes. tion, perforation, spontaneous bacterial peritonitis, and At the time of the patient’s second EGD for EVL, pulmonary infec tions.3,6-9,11,12 Complications of EVL, grade 3 varices were seen and again showed high-risk on the other hand, are generally benign.4,6-9,11 However, features. Three bands were successfully placed in the distal dysphagia following EVL has often been reported in esophagus. In the recovery suite following the procedure, the literature.6,10,11,13 Complete esophageal obstruction the patient complained of severe chest pain (giving it a causing dysphagia has been reported only once previ- score of 10 on a scale from 1 to 10) and was unresponsive ously in the literature.14 We report the second case of to both intravenous meperidine and a solution of alumi- complete esophageal obstruction following EVL. Our num hydroxide, magnesium hydroxide, simethicone, and patient was managed conservatively and experienced a viscous lidocaine. Within minutes of drinking the solu- good outcome. tion, the patient vomited white liquid with no evidence of blood. She was admitted to our hospital for further Case Report evaluation and treatment. Upon admission to our hospital, the patient was afe- A 67-year-old woman with Child-Pugh class A cirrhosis brile with normal vital signs (a heart rate of 60 beats per secondary to primary biliary cirrhosis (PBC) presented minute, respiratory rate of 18 breaths per minute, blood to our endoscopy suite to undergo her second esophago- pressure of 110/56 mmHg, and oxygen saturation rate gastroduodenoscopy (EGD) for band ligation of known of 100% on room air). Physical examination revealed an esophageal varices. The patient had been diagnosed with elderly female in no acute distress, and cardiopulmonary PBC 3 years previously. Four months prior to presenta- examination was unremarkable. Abdominal examination was notable for mild epigastric tenderness to palpation but no rebound or guarding. The patient’s bowel sounds Address correspondence to: were normo active, and the remainder of her examination Dr. Matthew A. Nikoloff, 835 Fifth Avenue, Chambersburg, PA 17201; E-mail: [email protected] was normal. Results from laboratory tests taken upon Gastroenterology & Hepatology Volume 7, Issue 8 August 2011 557 n I k o l o f f e t A l Figure 1. A gastrografin swallow study revealing complete obstruction at the level of the distal esophagus. No contrast or air is seen within the stomach. admission were normal, except for slightly elevated levels EVL has consistently demonstrated equal or better of total bilirubin, alkaline phosphatase, and aspartate efficacy compared to EST in terms of controlling acute aminotransferase, all of which were stable. An acute bleeding varices and lowering rebleeding rates and mor- abdominal series was within normal limits. tality.4,7,8,9,11 As these benefits have been achieved with On the second day of hospitalization, the patient’s fewer complications, EVL has become the standard-of- pain was slightly better; however, she was still unable to care treatment for esophageal varices.1,4-10 To perform tolerate liquids. She was also expectorating all of her oral EVL, the clinician places a small, elastic O-ring over secretions into an emesis basin and had slight odynopha- a small area of esophageal mucosa and submucosa.4,7,15 gia. A gastrografin swallow study was performed, showing The ensnared tissue is strangulated, leading to ischemia complete obstruction at the level of the distal esophagus and, eventually, sloughing, fibrosis, and variceal oblitera- (Figure 1). No contrast or air was noted in the stomach. tion.7,15 Given that this technique is purely mechanical, Due to the obstruction, the patient was started on partial transmural inflammation is not invoked, and systemic parenteral nutrition. complications are not seen.4,10 Complications commonly Fortunately, on the seventh day after her EGD, the described after EVL include stricture formation, ulcers, patient began to tolerate liquids. She was subsequently ulcer bleeding, pneumonia, and spontaneous bacterial discharged the following day. peritonitis.4,6-9,11 Ulcer formation is nearly universal, documented in 94% of patients on follow-up EGD.9,11,15 discussion Stricture formation occurs in 0% of patients in some reported series (n=64 and n=38), and an early meta- EVL was first introduced in 1986.4 Prior to EVL’s incep- analysis comparing EVL and EST revealed a stricture tion, EST was used to control active variceal bleeding odds ratio of 0.10 in favor of EVL.4,7,9 The occurrence and prevent recurrent hemorrhage. However, due to its of transient dysphagia (lasting 24–72 hours) is vari- induction of tissue injury, EST is associated with com- able; this complication has been reported in anywhere plications in nearly 40% of patients.4-6 Complications of from 0% to 75% of patients in various published case EST include stricture formation, ulceration of esophageal series.11,13 Engorged banded varices are the presumed mucosa, rebleeding, hematoma formation, perforation, cause of this phenomenon.6 Another unique complica- spontaneous bacterial peritonitis, and pulmonary infec- tion described by Berner and associates is altered lower tions.4,6-9,11,12 Stricture formation rates are as high as esophageal sphincter relaxation following EVL.10 How- 33%, and dysphagia occurs in 7–30% of patients who ever, significant differences in acid reflux and esophageal undergo EST.9,11,12 motility were not demonstrated.10 558 Gastroenterology & Hepatology Volume 7, Issue 8 August 2011 C o MP l e t e e s o phag e A l o b s t r u C t I o n f o l l o w I n G e V l To date, there has been only 1 case of esophageal summary obstruction as a complication of EVL that has been reported in the literature.14 A 58-year-old man with cir- Complete esophageal obstruction has been described in rhosis secondary to hepatitis C virus infection who had the literature only once before. In this case report, we a history of esophageal variceal bleeding had undergone present the second such case. Immediate complaints of 2 sessions of EST. He subsequently underwent 2 ses- dysphagia after banding—along with the presence of sial- sions of EVL 3 weeks apart. At the time of the first EVL orrhea or the inability to tolerate liquids—should suggest session, grade 3 varices were noted, and 4 bands were the possibility of obstruction. Obstruction can be docu- placed without difficulty. The second EVL session again mented by a contrast swallow study. If the patient has not revealed grade 3 varices, for which an additional 4 bands eaten recently (ie, there is no chance of a food impaction), were placed without complications. After endoscopy, the we do not recommend performing a repeat endoscopy, as patient resumed a normal diet and experienced chest it could dislodge a band and cause bleeding. Conservative discomfort and sialorrhea. An emergent upper endoscopy measures such as intravenous fluids and parenteral nutri- revealed food stuck in the esophagus above the banded tion may be needed. With time, the varix should slough, varices. On inspection, the newly banded varices had and dysphagia should be relieved. completely obstructed the esophageal lumen. The authors postulated that the newly banded varices had swollen, References thereby completely occluding the lumen. Three pathophysiologic mechanisms have been 1. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W; Practice Guidelines Com- mittee of the American Association for the Study of Liver Diseases; Practice proposed to explain the occurrence of dysphagia fol- Parameters Committee of the American College of Gastroenterology. Prevention lowing EVL. The most commonly proposed mechanism and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. is stricture formation, which typically presents as late Hepatology. 2007;46:922-938. 2. Schepke M, Kleber G, Nürnberg D, et al. Ligation versus propranolol for the dysphagia, allowing time for fibrosis progression and primary prophylaxis of variceal bleeding in cirrhosis. Hepatology. 2004;40:65-72. stricture formation.6,7,13,15 Dysphagia that presents soon 3.
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