What are the indications, technique, follow‑up schedule, complications, and contraindications of endoscopic band ligation for primary and secondary prophylaxis of bleeding esophageal varices in patients with cirrhosis?

Endoscopic Band Ligation for Esophageal Varices

Indications

Endoscopic variceal band ligation (EVL) is the first-line endoscopic treatment for both acute variceal bleeding control and secondary prophylaxis after a bleeding episode in patients with cirrhosis. 1

Acute Bleeding

• EVL should be performed as soon as the patient is hemodynamically stable, ideally within 12 hours of admission 1, 2
• Vasoactive drugs (octreotide, somatostatin, or terlipressin) must be started immediately when variceal bleeding is suspected, even before endoscopy is performed 2

Secondary Prophylaxis (After Bleeding Episode)

• Following control of active variceal bleeding, varices should be eradicated using EVL as the method of first choice 1
• EVL is superior to sclerotherapy, with significantly lower rates of rebleeding (OR 0.52), mortality (OR 0.67), and complications such as esophageal stricture (OR 0.10) 1

Primary Prophylaxis (Before First Bleed)

• EVL may be used for primary prophylaxis in patients with large varices who have contraindications or intolerance to beta-blockers 3
• EVL is highly effective in preventing first variceal bleed in liver transplant candidates, with only 2% failed prophylaxis rate 4
• However, EVL should NOT be used for fundal varices (GOV2 and IGV1) due to significantly increased risk of catastrophic bleeding 5

Contraindications

• Fundal varices (GOV2, IGV1): EVL is dangerous for gastric varices given their anatomy and may cause catastrophic bleeding 1, 5
• Active bleeding with severe hemodynamic instability requiring immediate balloon tamponade as a bridge to definitive therapy 2
• Severe coagulopathy should be corrected, though routine correction before prophylactic banding in stable patients is not recommended 6

Technique

Banding Protocol

• Each varix should be banded with a single band per session 1
• Sessions should be repeated at weekly intervals until complete variceal eradication is achieved 1
• An average of 2.6 banding episodes per patient is typically required for complete eradication 4
• The overtube should be avoided because it is associated with increased complications 1

Adjunctive Therapy

• Pre-endoscopy erythromycin (250mg IV, 30-120 minutes before) may be considered to facilitate the procedure 2
• Vasoactive drugs should be continued for 2-5 days post-endoscopy in acute bleeding scenarios 1, 2
• Antibiotic prophylaxis (ceftriaxone 1g/24h for maximum 7 days) should be administered in any patient with cirrhosis and GI hemorrhage 6, 2

Follow-Up Schedule

Post-Eradication Surveillance

• Following successful eradication, patients should be endoscoped at 3 months, then every 6 months thereafter 1
• If varices recur during surveillance, they should be treated with repeat variceal eradication 1
• Adding propranolol to EVL significantly reduces variceal recurrence (9% vs 38% with EVL alone) 7

Post-Procedure Monitoring for Bleeding

• After elective EVL, 75% of bleeding episodes occur within 4 days, so surveillance can reasonably be restricted to this period 8
• After emergency EVL for acute bleeding, patients should be kept under medical surveillance for 11 days, as 20 of 22 bleeding events occurred within this timeframe 8
• The overall bleeding rate after elective EVL is 3.9%, significantly lower than after emergency treatment (12.1%) 8

Complications

Bleeding Complications

• Overall bleeding rate after EVL is 7.8%, with bleeding from ligation ulcers occurring in 0.5-7.1% depending on whether the procedure was elective or emergent 8
• Band-induced ulcer bleeding occurs in approximately 1.2% of cases 4
• Three episodes of acute hematemesis from band-induced ulceration may occur, though this rate is low compared to the predicted rate of variceal bleeding 4

Other Complications

• Esophageal stricture formation is rare (OR 0.10 compared to sclerotherapy), with only 1% developing mild stricturing without dysphagia 1, 4
• EVL can be safely performed in anticoagulated patients (INR >2) without increased bleeding risk, though this is based on limited case series data 9

Management of Failed Prophylaxis

• Failed prophylaxis occurs in approximately 2% of patients undergoing primary prophylaxis 4
• If bleeding is difficult to control despite EVL, insert a Sengstaken-Blakemore tube as a temporary bridge (maximum 24 hours) until TIPS can be performed 2
• TIPS is the rescue therapy of choice for persistent bleeding or early rebleeding (10-15% of cases) despite standard therapy 2

Combination Therapy Considerations

Beta-Blockers Plus EVL

• Adding non-selective beta-blockers to EVL improves efficacy by reducing variceal recurrence from 38% to 9% 7
• After variceal eradication with EVL, transition to oral non-selective beta-blockers once vasoactive drugs are discontinued 6
• Combination therapy of sclerotherapy/EVL and non-selective beta-blockers may be used, or beta-blockers alone if hepatic venous pressure gradient can be confirmed reduced to <12 mmHg 1

Hemodynamic Monitoring

• Target hemodynamic response is HVPG reduction to <12 mmHg or >10-20% decrease from baseline, which protects against acute variceal bleeding 6
• Hemodynamic responders to beta-blockers (HVPG decrease to <12 mmHg or >20% reduction) have marked reduction in hemorrhage risk and may not need further endoscopic treatment 3