For an adult with portal hypertension and grade II or larger esophageal varices who has bled previously or is high risk, and who can tolerate sedation without uncontrolled coagulopathy (INR > 1.5 or platelet count < 50 × 10⁹/L) or severe infection, when is endoscopic variceal ligation indicated, how is the procedure performed, and what are the recommended follow‑up and alternative treatments?

Endoscopic Variceal Ligation for Portal Hypertension

Endoscopic variceal ligation (EVL) is the definitive endoscopic treatment for adults with portal hypertension and grade II or larger esophageal varices who have bled or are at high risk, achieving 85–90% initial hemostasis when combined with vasoactive drugs. 1, 2

Indications for EVL

Acute variceal hemorrhage:

• EVL is indicated immediately upon endoscopic confirmation of bleeding esophageal varices, performed during the same procedure as diagnostic endoscopy (within 12 hours of presentation after hemodynamic stabilization). 3, 1
• EVL is superior to sclerotherapy with lower rebleeding rates (OR 0.52), lower overall mortality (OR 0.67), and fewer complications. 2
• Sclerotherapy should only be used when EVL is technically impossible or unavailable. 3, 1

Secondary prophylaxis after previous bleeding:

• EVL is indicated for patients who have bled previously to prevent rebleeding, particularly when combined with non-selective beta-blockers (superior to either therapy alone). 1

Primary prophylaxis (high-risk patients):

• EVL is reserved for patients with contraindications or intolerance to beta-blockers, as beta-blockers remain first-line for primary prophylaxis. 4

Pre-Procedure Requirements

Immediate pharmacotherapy (start before endoscopy):

• Initiate vasoactive drugs immediately upon clinical suspicion of variceal bleeding—do not wait for endoscopy. 3, 2
• First choice: Terlipressin 2 mg IV every 4 hours for 48 hours, then 1 mg IV every 4 hours. 3
• Alternatives if terlipressin unavailable: Octreotide 50 µg IV bolus then 50 µg/hour infusion, or somatostatin 250 µg IV bolus then 250–500 µg/hour infusion. 3, 2
• Continue vasoactive drugs for 5 days after EVL to prevent early rebleeding. 3

Antibiotic prophylaxis:

• Ceftriaxone 1 g IV daily (maximum 7 days) is mandatory—reduces mortality, bacterial infections, and rebleeding. 3, 2
• Alternative: Norfloxacin if ceftriaxone unavailable. 3

Resuscitation targets:

• Restrictive transfusion strategy: Target hemoglobin 7–9 g/dL to avoid increasing portal pressure. 3, 1, 2
• Volume replacement with crystalloids initially, then blood products as needed. 3

Endoscopy preparation:

• Erythromycin 250 mg IV 30–120 minutes before endoscopy improves gastric visibility (unless QT prolongation contraindicated). 3, 2

Technical Procedure

Acute bleeding session:

• Perform EVL during the initial diagnostic endoscopy once variceal bleeding is confirmed. 3
• Use multishot band devices allowing placement of 2–10 bands per session depending on varix number and size. 1, 4
• Band placement targets variceal channels in the distal esophagus. 5

Eradication protocol:

• Repeat EVL sessions every 2–8 weeks (typically every 2–3 weeks) until complete variceal eradication. 1, 4
• Eradication is achieved in approximately 90% of patients after an average of 2–4 sessions. 1, 4, 6

Special considerations for gastric varices:

• GOV1 varices (extending along lesser curvature): Treat identically to esophageal varices with EVL; 64.7% disappear after esophageal EVL alone. 1, 2
• Only apply EVL to small GOV1 varices when the complete vessel can be suctioned into the ligation device. 1, 2
• Fundal varices (GOV2/IGV1): Never use EVL—use cyanoacrylate injection instead to avoid band detachment and catastrophic rebleeding. 2

Post-Procedure Management

Immediate care:

• Administer proton pump inhibitor therapy immediately after EVL to reduce post-ligation ulcer complications. 1, 2
• Continue vasoactive drugs for full 5-day course. 3
• Continue ceftriaxone for up to 7 days. 3

Surveillance protocol:

• First surveillance endoscopy 1–6 months after variceal eradication. 2
• Subsequent surveillance every 6–12 months indefinitely, as varices recur in 20–75% of patients. 1, 4
• Repeat EVL sessions as needed for recurrent varices. 4

Long-term secondary prophylaxis:

• Combine EVL with non-selective beta-blockers for superior rebleeding prevention compared to EVL alone. 1
• Critical pitfall: Do NOT use beta-blockers during acute bleeding—reserve for secondary prophylaxis after bleeding is controlled. 2

Rescue Therapy for EVL Failure

Definition of failure:

• Fresh hematemesis ≥2 hours after EVL, hypovolemic shock after treatment, or hemoglobin drop ≥3 g/dL within first 5 days. 7
• Occurs in 10–20% of patients despite optimal combined therapy. 2

Immediate rescue:

• Transjugular intrahepatic portosystemic shunt (TIPS) with covered stents is the recommended rescue treatment. 1, 2
• Balloon tamponade (maximum 24 hours) or removable esophageal stents serve as bridge therapy until TIPS. 2, 7

Early TIPS for high-risk patients (within 24–72 hours, ideally <24 hours):

• Child-Pugh B with active bleeding at endoscopy. 1, 2, 7
• Child-Pugh C with MELD score <14. 1, 2, 7
• Hepatic venous pressure gradient ≥20 mmHg measured within 24 hours. 2, 7
• Early TIPS achieves >90% hemostasis in rescue scenarios. 7

Critical Pitfalls to Avoid

• Do not delay vasoactive drugs waiting for endoscopy—start immediately upon clinical suspicion. 2
• Do not overtransfuse—maintaining hemoglobin >8 g/dL increases portal pressure and rebleeding risk. 2
• Do not use beta-blockers during acute bleeding—they are reserved for secondary prophylaxis only. 2
• Never attempt EVL on fundal varices—use cyanoacrylate injection to prevent band slippage and ulcer formation. 2
• Do not postpone EVL because of incidental non-bleeding gastric varices—treat the bleeding source first. 2

Expected Outcomes

Efficacy:

• Combined EVL plus vasoactive drugs achieves 77% 5-day hemostasis versus 58% with endoscopic treatment alone. 1
• EVL controls active bleeding in 85–90% of cases. 1, 2
• Variceal eradication achieved in 78–90% of patients. 6, 5

Complications:

• EVL has significantly fewer complications than sclerotherapy, with no major complications reported in large series. 4, 5
• Post-ligation ulcers are the most common minor complication (mitigated by PPI therapy). 1