What are the indications for Endoscopic Variceal Ligation (EVL)?

Indications for Endoscopic Variceal Ligation (EVL)

Endoscopic variceal ligation is indicated for three primary scenarios: acute esophageal variceal bleeding, prevention of rebleeding (secondary prophylaxis), and prevention of first variceal hemorrhage (primary prophylaxis) in patients with medium-to-large varices at high risk of bleeding. 1

Acute Esophageal Variceal Bleeding

EVL should be performed emergently in all patients presenting with acute esophageal variceal bleeding. 1 This represents the most critical indication, where endoscopic treatment must be initiated as soon as the patient is hemodynamically stabilized and the airway is protected. 1

• Endoscopy should be performed in all patients with suspected esophageal variceal bleeding to establish the diagnosis. 1
• Endoscopic treatment is mandatory when active bleeding is visualized, blood clots or white nipples appear on variceal surfaces, or blood is found in the stomach without another bleeding source. 1
• EVL should be combined with vasoactive agents (initiated immediately upon admission) and short-term antibiotic prophylaxis for optimal outcomes. 1

Secondary Prophylaxis (Prevention of Rebleeding)

The combination of EVL plus non-selective beta-blockers is the gold standard for preventing variceal rebleeding after an initial bleeding episode. 1 This combination therapy demonstrates superior outcomes compared to either modality alone, with significantly reduced rebleeding rates (RR 0.44,95% CI 0.28-0.69) and a trend toward decreased mortality. 1

Treatment Protocol for Secondary Prophylaxis

• EVL sessions should be repeated every 2-8 weeks until complete variceal eradication is achieved. 1
• First surveillance endoscopy should occur 1-3 months after variceal obliteration, then every 6-12 months to detect recurrence. 1
• If combination therapy cannot be performed, either non-selective beta-blockers or EVL alone is recommended rather than no treatment. 1
• Variceal rebleeding is defined as recurrent bleeding after at least 5 days without bleeding following recovery from acute hemorrhage. 1

A critical pitfall: EVL alone without beta-blockers is associated with higher overall mortality during follow-up (RR 1.25,95% CI 1.01-1.55) compared to beta-blockers alone, despite similar rebleeding rates. 1 This underscores the importance of NSBBs in addressing the underlying portal hypertension pathophysiology.

Primary Prophylaxis (Prevention of First Variceal Hemorrhage)

High-Risk Patients (Child B/C or Red Wale Markings)

For patients with medium-to-large varices who have never bled but are at high risk (Child-Pugh B/C classification or variceal red color signs on endoscopy), either non-selective beta-blockers or EVL may be used for primary prophylaxis. 1

• EVL significantly decreases the frequency of first variceal bleeding, with studies showing bleeding rates of 5-8.6% in the EVL group versus 20-39.4% in untreated controls. 2, 3
• In liver transplant candidates, EVL is highly effective with only 2% failed prophylaxis rate over 18 months of follow-up. 4
• Variceal eradication typically requires 2-4 sessions (mean 3.2-5.5 sessions) performed at 7-14 day intervals. 2, 4, 5

Lower-Risk Patients (Child A Without Red Signs)

For patients with medium-to-large varices at lower risk (Child-Pugh A without red signs), non-selective beta-blockers are preferred, with EVL reserved for patients with contraindications, intolerance, or non-compliance to beta-blockers. 1

Small Varices

For patients with small esophageal varices at high risk of bleeding (decompensated cirrhosis or red color signs), non-selective beta-blockers should be considered, but EVL is not typically indicated. 1

Special Considerations for Gastric Varices

• For gastroesophageal varices type 1 (GOV1) extending along the lesser curvature, follow the same guidelines as esophageal varices, as GOV1s often disappear when esophageal varices are eradicated by EVL (64.7% resolution rate). 1
• For GOV2 (extending to gastric fundus) and isolated gastric varices type 1 (IGV1), alternative treatments such as endoscopic variceal obturation are preferred over EVL. 1

Contraindications and Precautions

EVL should be performed with caution in patients on antiplatelet therapy due to increased bleeding risk from post-EVL ulcers, which occur in approximately 14% of cases. 6

• Proton pump inhibitors should be administered after EVL to reduce post-EVL ulcer size and bleeding risk, though long-term PPI use in cirrhosis may increase risks of spontaneous bacterial peritonitis and hepatic encephalopathy. 1, 6
• Common complications include transient dysphagia and chest discomfort, while severe complications like ulcer bleeding at ligation sites occur in approximately 1.2% of cases. 6, 4
• Esophageal stricture formation is rare (approximately 1% of patients). 4

When EVL is NOT Indicated

• EVL should not be used to prevent the development of varices in patients without existing varices. 1
• TIPS placement, not EVL, should be considered as rescue therapy when primary treatment for rebleeding fails. 1
• Early TIPS placement can be considered in patients at high risk of rebleeding rather than repeated EVL sessions. 1