Complete Esophageal Obstruction after Endoscopic Variceal Band Ligation in a Patient with a Sliding Hiatal Hernia

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Gastroenterology School of Medicine

Winter 1-18-2017

Complete Esophageal Obstruction a'er

Endoscopic Variceal Band Ligation in a Patient with

a Sliding Hiatal Hernia

Munthir Mansour MD

Yousef Abdel-Aziz MD

Hesham Awadh

Nihar Shah MD

Marshall University, [email protected]

Akash Ajmera

Marshall University, [email protected]du

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Recommended Citation

Mansour M, Abdel-Aziz Y, Awadh H, Shah N, Ajmera A. Complete Esophageal Obstruction a>er Endoscopic Variceal Band Ligation

in a Patient with a Sliding Hiatal Hernia. ACG Case Reports Journal. 2017;4:e8. doi:10.14309/crj.2017.8.

CASE REPORT | ESOPHAGUS

Complete Esophageal Obstruction after Endoscopic Variceal

Band Ligation in a Patient with a Sliding Hiatal Hernia

Munthir Mansour, MD

, Yousef Abdel-Aziz, MD

, Hesham Awadh, MD

, Nihar Shah, MD

,and

Akash Ajmera, MD

Department of Internal Medicine, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV

Department of Gastroenterology, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV

ABSTRACT

Complete esophageal obstruction is a rare complication of endoscopic variceal banding, with only 6 cases

in the English literature since the introduction of endoscopic variceal banding in 1986. We report a case of

complete esophageal obstruction following esophageal banding due to entrapment of part of a sliding hia-

tal hernia. To our knowledge, our case is one of few with esophageal obstruction post-banding, and the

ﬁrst associated with a hiatal hernia. We recommend caution when performing esophageal banding on

patients with a hiatal hernia.

INTRODUCTION

Endoscopic variceal ligation (EVL) is the deﬁnitive treatment of choice for active variceal hemorrhage. It is

a relatively simple procedure and is associated with fewer complications than endoscopic sclerotherapy.

Only 6 cases of complete esophageal obstruction following EVL have been reported in the English

literature.

CASE REPORT

A 65-year-old woman with a history of cirrhosis secondary to alcohol abuse, grade 1 esophageal varices, and a slid-

ing hiatal hernia (SHH) presented with hematemesis. She was found to have esophageal varices 2 years ago and

was started on nadolol. On examination, she had scleral icterus, and her laboratory tests were hemoglobin 10.7

g/dL, alanine aminotransferase 71 U/L, aspartate aminotransferase 120 U/L, international normalized ratio 1.4, se-

rum Na 145 mEq/L, serum creatinine 1 mg/dL, and total bilirubin 4 mg/dL. Esophagogastroduodenoscopy (EGD)

revealed 4 columns of grade 2 varices in the distal third of the esophagus. Two of the columns showed red wale

stigmata. Four ligation bands were successfully deployed.

The patient returned 3 weeks later for a repeat EVL. EGD revealed a small grade 1 varix in the distal third

of the esophagus (Figure 1). The patient had a large SHH and had hiccups during banding. Gastric tissue

slid upwards unpredictably during her hiccups, and a small amount of gastric tissue was caught in the band

when it was deployed. The patient tolerated the procedure well without other complications, and was dis-

charged home. She presented 3 days later for persistent nausea and non-bloody emesis. She did not toler-

ate any solids or liquids following the procedure. A barium swallow showed complete obstruction of the

distal esophagus.

EGD revealed a complete obliteration of the lumen at the gastroesophageal junction. An esophageal band with in-

advertent gastric tissue was seen. The tissue was edematous and blocking the lumen (Figure 2). No endoscopic

ACG Case Rep J 2017;4: e8. doi:10.14309/crj.2017.8. Published online: January 18, 2017.

Correspondence: Akash Ajmera, Department of Gastroenterology, Joan C. Edwards School of Medicine, Marshall University, 1249 15th St, Erma Ora Byrd Clinical

Center, Huntington, WV 25701 ([email protected]).

International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0.

ACG Case Reports Journal / Volume 4 acgcasereports.gi.org 1

ACG CASE REPORTS JOURNAL

intervention was attempted, and the patient was observed in

the hospital. She tolerated a diet after 3 days, and the

obstruction resolved spontaneously. She did well until 4

weeks later when she presented with dysphagia. An EGD

revealed a stricture at the distal end of the esophagus, with

difﬁculty passing the endoscope (Figure 3). With pressure,

the stricture was passed. Over the next 4 months, she

required 3 sessions of balloon dilation of the stricture with re-

solution of her symptoms (Figure 4).

DISCUSSION

Endoscopic variceal banding works by capturing the varices

causing venous occlusion from thrombosis and leading to

tissue necrosis. The bands slough off in a few days, leaving a

superﬁcial ulceration that rapidly heals. EVL has been associ-

ated with fewer complications and mortality than endoscopic

sclerotherapy.

1-6

Complications described after EVL include

transient dysphagia, stricture formation, ulcers, pneumonia,

and spontaneous bacterial peritonitis.

1-6

Complete esophageal obstruction following EVL is extremely

rare. Only 6 prior cases exist in the English literature.

7-12

Esophageal obstruction post-banding may occur secondary

to edema and necrosis at the banding area. It is believed that

placing a band close to mucosa that is damaged with edema

or necrosis may increase the risk of post-ligation obstruction.

We believe that allowing appropriate time for the damaged

mucosa to heal between banding is crucial to avoid this complica-

tion. There is limited evidence to support an optimal time inter-

val. It is likely that smaller varices are more prone to ulceration

and stricture formation due to greater injury to the surrounding

mucosa, thus increasing the risk of post-ligation obstruction.

Therefore, particular caution needs to be exercised in selecting

the right-sized varix for ligation, avoiding excessive suctioning of

mucosa surrounding varices, and a gentle examination of the

esophagus following the completion of EVL. One report recom-

mended that EVLs should be applied in a spiral fashion to avoid

extensive luminal compromise on one plane.

Our patient had a history of SHH and was hiccupping during the

procedure. We believe that hiccupping caused the hiatal hernia

to slide up during deployment of the band, causing it to get

caught in the band. Gastroenterologists should use caution when

banding patients with a hiatal hernia, especially if they are band-

ing in the distal esophagus or near the gastroesophageal junc-

tion. Active manipulation to alleviate the obstruction is generally

not successful, and conservative management is the accepted

approach for esophageal obstruction following EVL.

9-11

DISCLOSURES

Author contributions: M. Mansour, Y. Abdel-Aziz, and H.

Awadh wrote the manuscript. N. Shah and A. Ajmera edited

the manuscript. A. Ajmera is the article guarantor.

Figure 3. Esophageal stricture following esophageal obstruction.

Figure 4. Balloon dilation of the esophageal stricture.

Figure 1. Endoscopy showing small esophageal varices with red wale

stigmata.

Figure 2. Esophageal obstruction from banding of inadvertently caught

gastric tissue with necrotic tissue and edema surrounding the band.

Mansour et al Esophageal Obstruction after Esophageal Banding

ACG Case Reports Journal / Volume 4 acgcasereports.gi.org 2

Financial disclosure: None to report.

Informed consent was obtained for this case report.

Received May 7, 2016; Accepted October 7, 2016

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Mansour et al Esophageal Obstruction after Esophageal Banding

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