Complete Esophageal Obstruction Following Routine Esophageal Variceal Ligation

Abstract

A 67-year-old man with decompensated NASH cirrhosis presented for EGD for surveillance of esophageal varices. The patient was diagnosed 2 years prior when he presented with new-onset ascites. He underwent screening EGD previously, noting large (Grade III) esophageal varices and was started on non-selective beta blocker. However, he was intolerant secondary to presyncopal symptoms. He later presented with variceal hemorrhage necessitating variceal ligation; 2 bands were placed with hemostasis at that time. After initial episode of variceal ligation he was restarted on nonselective beta blocker. He underwent subsequent endoscopy 2 months later, where another band was placed for variceal ligation. Six weeks from his last variceal ligation, he presented for repeat routine outpatient variceal surveillance to ensure complete eradication. His EGD was notable for Grade II varices in the lower third of the esophagus; two bands were successfully placed (Figure A) with compete eradication, resulting in deflation of the varices. Immediately after the procedure, the patient complained of substernal chest pain, dysphagia, excessive salivation, nausea and had emesis in the recovery area. He was admitted overnight for observation. His symptoms continued despite symptom-targeted treatment that included antiemetic, proton pump inhibitors and intravenous fluid while was kept nill-by-mouth. In particular, he continued to be intolerant to oral secretions and to complain of dysphagia. Water soluble esophagram was obtained and was notable for complete luminal obstruction (Figure B). The patient was offered endoscopy for evaluation and possible intervention but he declined and opted to continue with the conservative management described earlier with addition of scopolamine patch. He eventually tolerated liquid diet 4 days following variceal ligation; repeat esophagram noted contrast passing into the stomach (Figure C).1721_A Figure 1 No Caption available.1721_B Figure 2 No Caption available.1721_C Figure 3 No Caption available.