When is endoscopic variceal ligation (EVL) banding indicated for esophageal varices and how is the procedure performed?

Endoscopic Variceal Ligation (EVL) Banding

EVL is the recommended endoscopic therapy for acute bleeding esophageal varices and should be combined with vasoactive drugs and non-selective beta-blockers for optimal outcomes, achieving 85-90% initial hemostasis rates and superior mortality reduction compared to sclerotherapy. 1

Indications for EVL

Acute Variceal Bleeding

• Perform EVL immediately for actively bleeding esophageal varices or varices with high-risk stigmata (red wale signs, cherry red spots) identified during emergency endoscopy. 1, 2
• EVL achieves hemostasis in approximately 90% of acute bleeding cases. 3
• Combine EVL with vasoactive drugs (terlipressin preferred, octreotide if unavailable) during acute bleeding—this combination is superior to either therapy alone. 1, 3

Primary Prophylaxis

• EVL is indicated for medium or large esophageal varices (>5mm) when non-selective beta-blockers are contraindicated or not tolerated. 1
• EVL is preferred over beta-blockers when high-risk bleeding stigmata are present (red wale signs, cherry red spots). 1
• In pre-liver transplant patients, EVL is highly effective for preventing first variceal bleed with only 2% failure rate. 4

Secondary Prophylaxis

• Initiate EVL on grade 2 esophageal varices with red wale signs during the same endoscopy that identified them as the bleeding source. 2
• Combination of EVL plus non-selective beta-blockers is the gold standard for secondary prophylaxis (Class I, Level A evidence)—superior to either modality alone. 2, 3

Procedural Technique

Standard Banding Approach

• Traditional technique involves banding from the distal esophagus upwards, placing bands circumferentially around variceal columns. 1
• Place 4-6 bands per session—using >5 bands per session does not increase complication rates. 5

Targeted Banding for Active Bleeding

• For varices with stigmata of recent bleeding (white nipple sign), deploy the first band directly at the bleeding stigmata site, then complete with standard circumferential banding. 6
• This targeted technique reduces active bleeding during endoscopy (6.5% vs 20% with conventional technique). 6

Repeat Sessions Until Eradication

• Schedule repeat EVL sessions every 2-8 weeks until varices are no longer ligatable, typically requiring 2-4 sessions (mean 2.8 sessions). 2, 3, 5, 7
• EVL requires fewer sessions than sclerotherapy (mean 2.91 vs 4.73 sessions). 1
• Interbanding intervals ≥3 weeks are associated with significantly lower rebleeding risk (hazard ratio 3.84) and fewer esophageal ulcers (15% vs 42% when interval <20 days). 8, 5

Combination Therapy Protocol

Pharmacologic Management

• Initiate non-selective beta-blockers (propranolol, nadolol, or carvedilol) within days after acute bleed is controlled. 2, 3
• Titrate to maximal tolerated dose targeting heart rate 55-60 bpm while maintaining systolic blood pressure ≥90 mmHg. 2
• Continue beta-blockers indefinitely, even after variceal eradication, because portal hypertension persists and varices recur in 19-28% of patients. 2, 5, 7

Vasoactive Drug Duration

• Continue vasoactive drugs (octreotide or terlipressin) for 3-5 days after endoscopic treatment to reduce early rebleeding. 3

Antibiotic Prophylaxis

• Administer ceftriaxone 1g IV daily for maximum 7 days in all patients with acute variceal hemorrhage. 3

Outcomes and Efficacy

Mortality and Rebleeding Benefits

• EVL reduces rebleeding rate (OR 0.52), mortality rate (OR 0.67), and death from bleeding (OR 0.49) compared to sclerotherapy. 1
• Long-term cumulative rebleeding rates after EVL are 1.6% at 1 year, 9.2% at 5 years, and 11.4% at 9 years. 7
• Variceal recurrence occurs in 19-28% of patients after eradication, typically within 53 months. 5, 7

Comparison to Other Modalities

• EVL achieves faster variceal obliteration than sclerotherapy with fewer complications. 1
• Combination EVL plus beta-blockers is superior to beta-blockers alone for preventing rebleeding. 2

Surveillance After Eradication

• Perform first surveillance endoscopy 1-6 months after variceal eradication. 2, 3
• Subsequent surveillance every 6-12 months to detect recurrence. 2, 3
• If varices recur, repeat EVL treatment is indicated. 2

Complications and Risk Mitigation

Post-EVL Ulcers

• Post-EVL ulcers occur in approximately 14% of cases. 9
• Administer proton pump inhibitors (pantoprazole 40mg IV after EVL, then 40mg oral daily for 9 days) to reduce ulcer size and bleeding risk. 9

Patients on Antiplatelet Therapy

• EVL can be performed in patients on antiplatelet therapy with additional precautions: use PPI therapy before and after procedure, and monitor closely post-procedure. 9
• For primary prophylaxis in high bleeding risk patients, consider non-selective beta-blockers as alternative to EVL. 9

Other Complications

• Most common complications are transient dysphagia and chest discomfort. 9
• Esophageal stricturing occurs in approximately 1% of patients. 4
• Band-induced bleeding occurs in 1.2% of sessions. 4

Critical Pitfalls to Avoid

• Do not delay EVL when high-risk varices are identified in a patient with recent bleeding. 2
• Do not rely on EVL alone without adding non-selective beta-blockers—combination therapy is the standard of care. 2
• Do not discontinue beta-blockers after variceal eradication, as portal hypertension persists and varices may recur. 2
• Do not use sclerotherapy instead of EVL—it has higher complication rates and requires more sessions. 2
• Do not combine EVL with sclerotherapy—this increases esophageal stricture risk without improving outcomes. 2
• Do not use TIPS as first-line therapy; reserve it for rescue situations after combined EVL and pharmacologic therapy fails. 2, 3
• Do not schedule EVL sessions <3 weeks apart—longer interbanding intervals (≥3 weeks) significantly reduce rebleeding risk and esophageal ulcer formation. 8, 5

Rescue Therapy When EVL Fails

• TIPS is reserved for patients who fail combined EVL and beta-blocker therapy, or for high-risk patients (Child-Pugh C or Child-Pugh B with active bleeding at endoscopy). 2, 3
• Early TIPS (within 72 hours) should be considered in Child-Pugh B patients with active bleeding or Child-Pugh C patients with MELD <14. 1
• TIPS carries 35% risk of hepatic encephalopathy versus 14% with combination endoscopic/medical therapy. 1, 2