Bridgeport Hospital/Yale New Haven Health Bridgeport, CT
Jamil O. Alexis, MD1, Saddam Zaidi, MD2, Mark S. McFarland, MD1, Caroline Loeser, MD2, Lucy Shamberg, MD3 1Bridgeport Hospital/Yale New Haven Health, Bridgeport, CT; 2Yale New Haven Health/Bridgeport Hospital, Bridgeport, CT; 3Bridgeport Hospital/Yale New Haven Health, Stratford, CT
Introduction: Esophageal variceal banding is a commonly performed procedure, albeit not without risks. Dysphagia, odynophagia, esophageal ulcerations, and strictures are well-documented complications of esophageal variceal banding. However, complete circumferential obstruction of the esophageal lumen is an uncommon occurrence. We present a unique case of a patient who developed esophageal obstruction following esophageal variceal band ligation that was managed with thermal endoscopic resection of the obstructing lesion.
Case Description/Methods: An 80-year-old woman with past medical history of cirrhosis secondary to non-alcoholic steatohepatitis and atrial fibrillation receiving chronic anticoagulation therapy with apixaban, presented with dysphagia and odynophagia one day after undergoing an upper endoscopy with esophageal variceal band ligation. Despite being hemodynamically stable and showing no signs of overt gastrointestinal bleeding, the patient experienced no difficulty tolerating oral secretions during initial evaluation. An esophagram revealed obstruction in the distal esophagus. An upper endoscopy was performed to evaluate the cause of the obstruction. The esophagus was obstructed by a large, banded varix at approximately 36 cm from the incisors. Initial attempts to remove the variceal band using endoscopic shears were unsuccessful, necessitating the use of a hot snare to remove tissue above the band. This approach facilitated subsequent removal of the band with rat-tooth forceps, revealing a stenosed yet patent lumen that was traversed using an ultra-slim 5.8 mm endoscope. To ensure adequate nutrition, a nasogastric feeding tube was placed under endoscopic guidance. Within two days of the procedure, the patient was able to tolerate a pureed diet and was discharged with home anticoagulation therapy. A follow-up evaluation one month later revealed that the patient was tolerating a full diet without any symptoms or further complications.
Discussion: Few reports exist regarding the management of such esophageal obstruction after variceal banding. Approaches have varied from conservative therapy with parenteral nutrition and monitoring to surgical intervention. Despite the rarity of this complication, we demonstrate the successful management of this challenging scenario through endoscopic intervention, allowing for the resumption of chronic anticoagulation therapy and complete resolution of symptoms.
Figure: Complete obstruction of esophageal lumen after variceal banding noted in Image A. Esophageal stricture after endoscopic resection of necrosed varix noted in Image B.
Jamil Alexis indicated no relevant financial relationships.
Saddam Zaidi indicated no relevant financial relationships.
Mark McFarland indicated no relevant financial relationships.
Caroline Loeser indicated no relevant financial relationships.
Lucy Shamberg indicated no relevant financial relationships.
Jamil O. Alexis, MD1, Saddam Zaidi, MD2, Mark S. McFarland, MD1, Caroline Loeser, MD2, Lucy Shamberg, MD3. P1932 - A Case of Complete Esophageal Obstruction Following Esophageal Variceal Banding, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.