In a patient with portal hypertension (e.g., cirrhosis) and non‑bleeding gastric varices, is endoscopic variceal ligation (EVL) of the bleeding esophageal varices advisable?

Band Ligation for Bleeding Esophageal Varices with Concurrent Non-Bleeding Gastric Varices

Yes, endoscopic variceal ligation (EVL) should be performed for bleeding esophageal varices even in the presence of non-bleeding gastric varices, as the two are managed independently based on their bleeding status and anatomical classification.

Treatment Algorithm Based on Variceal Type

Esophageal Varices (Actively Bleeding)

• Immediate EVL is indicated for bleeding esophageal varices, achieving 85-90% initial hemostasis rates when combined with vasoactive drugs 1.
• EVL combined with vasoactive agents (terlipressin, octreotide, or somatostatin) achieves superior 5-day hemostasis (77%) compared to endoscopic treatment alone (58%) 1.
• Start vasoactive drugs immediately upon suspicion of variceal bleeding, before endoscopy, and continue for 2-5 days 2, 3.
• Administer prophylactic antibiotics (ceftriaxone 1g IV daily) to reduce mortality, bacterial infections, and rebleeding 1, 2.

Gastric Varices (Non-Bleeding): Classification Determines Management

The presence of non-bleeding gastric varices does not contraindicate EVL for bleeding esophageal varices, but their management depends on classification 1:

GOV1 (Gastro-esophageal Varices Type 1)

• GOV1 varices extending along the lesser curvature are managed identically to esophageal varices 1, 2.
• GOV1 varices often resolve spontaneously after esophageal EVL—64.7% disappear following esophageal variceal eradication, so separate treatment is usually unnecessary 4.
• If GOV1 varices are small and non-bleeding, proceed with EVL of the bleeding esophageal varices without additional intervention 1.

GOV2 and IGV1 (Fundal Varices)

• Fundal varices (GOV2 and IGV1) require different endoscopic technique if they bleed—cyanoacrylate injection rather than EVL 1, 2.
• Non-bleeding fundal varices do not require immediate intervention during acute esophageal variceal bleeding 1.
• EVL should not be attempted on fundal varices, as bands will fall off leaving ulcers that can cause catastrophic rebleeding 1.

Critical Technical Considerations

When EVL Is Safe Despite Gastric Varices

• EVL is the recommended endoscopic therapy for acute bleeding esophageal varices, endorsed by the Baveno VI Consensus 1.
• EVL reduces rebleeding rates (OR 0.52), mortality (OR 0.67), and bleeding-related death (OR 0.49) compared to sclerotherapy 1.
• Repeat EVL every 2-8 weeks until variceal eradication is achieved, typically requiring 2-3 sessions 4.

When to Exercise Caution

• Large fundal varices (GOV2/IGV1) increase rebleeding risk 5-fold and predict treatment failure 5.
• If massive bleeding occurs from gastric varices during the procedure, balloon tamponade with Linton-Nachlas tube may serve as a bridge to definitive therapy 1.
• Do not attempt EVL on gastric varices unless they are small GOV1 varices where both mucosal walls can be suctioned into the ligator 1.

Post-Procedure Management

• Administer proton pump inhibitors immediately after EVL to reduce post-ligation ulcer complications 1, 4.
• Monitor for early rebleeding, which occurs in 10-20% of patients despite optimal therapy 2.
• Continue surveillance endoscopy 1-6 months after variceal eradication, then every 6-12 months, as varices can recur 1.

Rescue Therapy for Treatment Failure

• Early TIPS (transjugular intrahepatic portosystemic shunt) within 24-72 hours should be considered for high-risk patients: Child-Pugh B with active bleeding, Child-Pugh C with MELD <14, or HVPG ≥20 mmHg 1, 2.
• TIPS is more effective than cyanoacrylate injection for preventing rebleeding from gastric varices if they subsequently bleed 1.

Common Pitfalls to Avoid

• Do not delay EVL because of incidental non-bleeding gastric varices—treat the bleeding source first 1.
• Do not use EVL on fundal varices—this causes band slippage and ulcer formation over the vessel 1.
• Do not withhold vasoactive drugs while awaiting endoscopy—start immediately upon clinical suspicion 2, 3.
• Do not overtransfuse—maintain restrictive strategy (hemoglobin 7-9 g/dL) to avoid increasing portal pressure 1, 2.