Complete Esophageal Obstruction after Endoscopic Variceal Ligation

Abstract

Introduction: Endoscopic variceal ligation (EVL) has become standard of care for treatment of esophageal varices. Although considered safe, complications of EVL have been reported. Complete esophageal obstruction after EVL is extremely rare. We report only the third case of complete esophageal obstruction following EVL. Case Presentation: A 64-year-old male with Hepatitis C and alcoholic cirrhosis underwent esophagogastroduodenoscopy (EGD) for variceal screening. EGD revealed two columns of varices. EVL was performed with four bands. Patient developed chest pain, vomiting, and dysphagia to even liquids shortly after going home and came back to the emergency room. CT chest revealed dilation of esophagus and wall thickening in the distal third without any perforation. He was kept NPO and monitored. Due to persistent dysphagia and difficulty tolerating oral secretions, repeat EGD was performed. This revealed food at mid-esophagus. Scope was passed into the distal esophagus but despite multiple attempts, no opening could be seen and the gastroesophageal junction was not visualized. Previously placed band was seen overlying the obstructed site. Patient was unable to tolerate soft diet even after 4 days, so repeat EGD was performed for persistent dysphagia. It revealed two large necrotic, post-banded varices in the distal esophagus, moderately obstructing the esophagus. A cold snare was used to dislodge the necrotic tissue and pushed into the stomach. Post-procedure, patient was able to tolerate diet and was discharged home. Discussion: Endoscopic variceal ligation (EVL) is used for primary prophylaxis in patients with medium or large varices or patients intolerant to beta blocker. EVL has supplanted endoscopic sclerotherapy (EST), due to lower complications. Although considered safe, complications of EVL include perforation, pain, rebleeding, altered esophageal motility, bacteremia, and stenosis. Late dysphagia is due to stricture formation. Dysphagia that presents soon after EVL as in our case may be due to transient alterations in esophageal motility. Altered lower esophageal sphincter relaxation after EVL also occurs. Prior to initial EGD, the esophagus may have undetected strictures or Schatzki's ring. If a varix is banded proximally, the peristalsis of the esophagus propagates the banded varix into the strictured segment, creating a ball-valve effect. The effects are similar to food impaction caused by Schatzki's ring. The stalk created by a banded varix prevents distal propagation of the varix until it sloughs off. Complete esophageal obstruction following EVL is extremely rare. Immediate complaints of dysphagia along with sialorrhea or inability to tolerate liquids should raise concern for obstruction.