When banding goes bad: two rare complications of endoscopic variceal banding ligation

Abstract

Endoscopic variceal band ligation (EVBL) is a key therapy for the management of esophageal varices in patients with cirrhosis, but complications, though infrequent, can have significant clinical implications. We report a rare case of a 76-year-old woman with metabolic-associated steatotic liver disease cirrhosis who developed esophageal obstruction followed by a severe esophageal stricture after EVBL. Initial symptoms included dysphagia and chest pain, which led to the discovery of complete esophageal obstruction secondary to sloughing mucosa and detached bands on endoscopy. After endoscopic removal of the obstructing material, the patient initially had improvement in symptoms, but these symptoms recurred with repeat endoscopy, demonstrating a severe esophageal stricture requiring serial dilations. This case underscores the importance of vigilance in recognizing and managing two rare complications of EVBL, esophageal obstruction and stricture development, to improve patient outcomes.

KEY POINTS

• Endoscopic variceal band ligation (EVBL) has emerged as the first-line treatment for the prophylactic and therapeutic management of esophageal varices due to its effectiveness in reducing the incidence of variceal hemorrhage, a potentially life-threatening complication in cirrhotic patients.

• Although EVBL is regarded as safe, various complications have been reported, ranging from common events such as recurrent bleeding and esophageal ulceration to rarer, yet more severe events, such as esophageal obstruction and stricture formation.

• It is crucial to identify these complications promptly to provide appropriate management and to improve patient outcomes.

CME

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CASE SUMMARY

A 76-year-old woman with a history of metabolic-associated steatotic liver disease cirrhosis presented to the hospital with symptoms of weakness and fatigue for 2 weeks. She denied any hematemesis, hematochezia, or melena. Laboratory work demonstrated a hemoglobin of 6.4 g/dL from a baseline of 12.4 g/dL (normal 12–16 g/dL). She underwent upper endoscopy, which showed two nonbleeding cratered clean-based gastric ulcers in the gastric antrum. She was also noted to have grade II esophageal varices with red whale sign (Figure 1a) and underwent endoscopic variceal band ligation (EVBL) with two bands placed with complete eradication (Figure 1b). No other mucosal or structural abnormalities were found in the esophagus.

Figure 1.

(a) Grade II esophageal varices with red whale sign (arrow). (b) Endoscopic variceal band ligation with two bands placed. (c) Computed tomography of the abdomen and pelvis without contrast demonstrating hyperdense material in the esophagus (arrow). (d) Detached bands and sloughing mucosa at the site of variceal banding causing esophageal obstruction. (e) Esophageal stricture at site of endoscopic variceal band ligation. (f) Esophageal stricture after serial Savary bougie dilations.

The patient developed chest pain, dysphagia to solids, and regurgitation symptoms 1 day after the procedure. Her symptoms continued to persist over several days, where she was unable to tolerate oral intake, and a computed tomography scan of the abdomen and pelvis without contrast showed hyperdense material in the distal esophagus (Figure 1c). To further evaluate these imaging findings and rule out the possibility of a food impaction, a repeat upper endoscopy was performed, which showed complete obstruction of the esophageal lumen secondary to detached bands and sloughing mucosa with ulceration in the lower third of the esophagus at the site of variceal banding (Figure 1d). The detached bands and obstructing sloughing mucosa were removed with resolution of her symptoms. The patient was discharged on a soft diet, proton pump inhibitor, and sucralfate.

At home, she initially tolerated solids but developed dysphagia again to solids which progressed to liquids with a 6-pound weight loss a week after hospital discharge. Repeat upper endoscopy performed due to her recurrent dysphagia symptoms showed no esophageal varices, but a severe esophageal stricture measuring 4 mm in diameter (Figure 1e) located approximately 3 cm above the gastroesophageal junction at the site of prior banding and subsequent obstruction. Random esophageal biopsies were negative for eosinophilic or lymphocytic esophagitis, and biopsies of the esophageal stricture were negative for dysplasia or malignancy. As alternative causes for the stricture were ruled out, her esophageal stricture was believed to be secondary to esophageal obstruction from EVBL.

The patient underwent esophageal dilation with Savary bougie dilators every 2 to 3 weeks, which initially required fluoroscopic guidance as the stricture was unable to be traversed with a regular or ultra-slim upper endoscope. Due to the severity of the patient’s stricture, triamcinolone injection was also performed at the stricture site. The stricture diameter improved with serial dilations (Figure 1f), and she is now able to tolerate a regular diet with resolution of her symptoms.

CLINICAL QUESTIONS

1. A 60-year-old man with a history of alcoholic cirrhosis underwent EVBL for grade III esophageal varices. About 10 days later, he reported progressive difficulty swallowing both solids and liquids. Repeat upper endoscopy revealed a 5 mm esophageal stricture at the gastroesophageal junction. What is the most appropriate next step in management?

   1. Immediate placement of a self-expanding metal stent

   2. Esophageal dilation with Savary bougie dilators

   3. Revision of EVBL procedure

   4. Emergent surgical resection of the stricture

2. What is the incidence of esophageal strictures following EVBL?

   1. Less than 1%

   2. Approximately 5%

   3. Between 10% and 15%

   4. More than 20%

Answers are provided at the end of the article.

DISCUSSION

Dysphagia symptoms following EVBL have various potential causes depending on the timing of symptom onset, underlying anatomical abnormalities, and prior banding history.^1–3 If dysphagia symptoms occur immediately after EVBL, they may be due to a temporary blockage from the swollen banded varix or changes in the function of the lower esophageal sphincter.³ Additionally, preexisting esophageal structural anomalies, such as a Schatzki’s ring, can contribute to symptoms if the banded varix is pushed into a constricted area, creating a ball-valve effect.¹ Dysphagia symptoms occurring immediately after EVBL typically resolve as the necrotic banded mucosa sloughs off over the course of several days. In cases where dysphagia persists after EVBL, endoscopic evaluation is crucial to rule out mechanical obstruction. In this case, the removal of detached bands and sloughing mucosa was necessary in treating the mechanical obstruction with overall low risk of bleeding, as the esophageal varices had already been treated. Chronic dysphagia, occurring in up to one-third of patients after EVBL, can also arise without evident mechanical obstruction, although the precise mechanism remains unclear.²

Esophageal stricture formation following EVBL is rare, with an incidence of <1%, and can develop weeks to months after EVBL.⁴ Stricture formation after EVBL is thought to result from mucosal necrosis progressing to fibrosis, with risk factors including banding small varices (where surrounding normal mucosa may be banded in addition to the varices) and placing bands on the same plane. In such cases of stricture formation, esophageal dilation has been proven to be effective as first-line treatment, with esophageal stent placement and surgery considered in cases refractory to dilation.^5,6

Historically, before EVBL became standard practice, endoscopic sclerotherapy was the treatment of choice. However, endoscopic sclerotherapy was associated with higher rates of esophageal stricture formation,⁷ whereas EVBL is associated with a lower incidence of strictures.⁸ EVBL is well tolerated, but nevertheless the procedure can be associated with various complications. Common complications include esophageal obstruction, ulceration, bleeding, and infection, which can cause symptoms such as dysphagia, odynophagia, retrosternal chest pain, throat pain, and/or heartburn.^9,10

Overall, persistent dysphagia after EVBL should prompt repeat upper endoscopy to assess for structural causes. Our case illustrates two rare complications after EVBL with esophageal obstruction and subsequent esophageal stricture development, highlighting the importance of early recognition and intervention.

ANSWERS TO CLINICAL QUESTIONS

Question 1, b. Esophageal dilation with Savary bougie dilators is the first-line treatment for benign strictures that occur after EVBL. This method is effective in most patients and helps restore the esophageal lumen’s patency. Self-expanding metal stents and surgery may be considered for refractory cases but are not typically the first choice in this scenario.

Question 2, a. Esophageal strictures following EVBL are rare, with an incidence of less than 1%, yet they can lead to significant morbidity if not promptly identified and managed.⁴ Before EVBL became standard practice, endoscopic sclerotherapy was the treatment of choice but was associated with higher rates of esophageal stricture formation.⁷ EVBL, in contrast, is linked to a lower incidence of strictures.⁸

Disclosure statement/Funding

The planners and faculty for this activity have no relevant financial relationships to disclose. The authors report no funding. The patient consented to publication of this case report.