Abstract
Esophageal varices ligation is a common procedure with a low complication rate. Complete esophageal occlusion following this procedure is rare and the majority of cases resolve with conservative management. We present a novel technique of guide wire passage and balloon dilation. A 46-year-old female presented with alcoholic cirrhosis. EGD demonstrated large >5mm varices. 4 ligation bands were placed with incomplete eradication. EGD a month later placed another 4 bands without problems. One month later, EGD showed multiple large varices traversing a non-circumferential stenosis near the EG junction. The scope with the attached bander would not traverse the EGJ. A single band was placed above the stenosis resulting in obliteration of varices and resulted in obstruction of the esophageal lumen. The patient initially did not have dysphagia. The next day, the patient re-presented with dysphagia and odynophagia to solids and liquids. Occlusion secondary to banding was suspected and standard conservative management was attempted for 3 days. Due to lack of improvement, an esophagogram was performed identifying complete esophageal obstruction. An EGD demonstrated a completely obstructed lower esophagus with band ulceration blocking passage of the adult EGD scope and the afore mentioned band was still in place. A minimal lumen was seen on close examination. A 0.35 Zebra ERCP wire was passed through the stenotic area. A TTS dilator was then passed over the wire. The stenosis was dilated to 10mm with an 8-9-10mm balloon dilator. Then a stricture gastroscope was passed into the gastric lumen demonstrating improvement of narrowing. The patient's symptoms resolved and no complications occurred. A benign stricture approx. 8-10 mm in diameter was identified on repeat EGD 1 week later. The site underwent balloon dilation and the patient was scheduled for repeat dilations. This case demonstrated that a stricture was formed due to scarring from previous ligations with repeat banding resulting in complete occlusion. Standard therapy calls for 7 days of prior therapy before endoscopic intervention but if the patient's condition does not allow observation, early intervention should be considered. A thorough understanding of the cause of the occlusion and tools available allowed for a novel solution to this patient's condition. In the future, this method may be considered as an alternative therapy in esophageal occlusion following variceal banding.