Endoscopy - Management of Bleeding Esophageal Varices
What to Band?
- Always find the varix that bled (white nipple sign) and band it first or on the lowest point of that specific variceal column.
- Avoid dislodging the fibrin plug. It can be banded directly but anticipate active bleeding since it has tendency to burst.
- If without bleeding, start with the most distal varix and band upwards at intervals of 2cm in a spiral fashion.
- Varices in the mid or upper third need not be banded if the lower third is eradicated.
EGD and the Banding Procedure:
- Always hold the scope in the same position to be sure where the columns are.
- When you're committed to band, don't hesitate, position the cap in the bleeder and suction firmly until there is red out before firing the band. Maintain suction for 3-5 seconds afterwards so that the band can reach the varix base.
- After banding, slowly pull back the scope to prevent band dislodgement.
- If you can't suction the varix adequately, pull back gently and jiggle the tip of the scope gently to allow more varix in. If it is still not being suctioned, abort and place the band somewhere else.
- When sucking, be apposed. Don't push too hard since it will make it harder to suction.
- If with an actively bleeding varix upon scoping for the first time, consider a clip. It could be a bloodbath when you go back in with a bander.
- When the patient is not actively bleeding, take your time with the banding. Select each varix carefully. Deep ulcers form when bands are applied haphazardly on the mucosa rather than the varix.
- If the varix did not blanch after banding, you haven't banded the one that bled yet.
- Sometimes during banding, varices disappear earlier than you thought they would.
- Avoid placing more bands because it will lead to higher rate of post-band ulcers.
- Ask the nurses and techs what they see too. Many of them have seen hundreds of varices and are good at spotting troublesome ones.
By Dr. Steven Bollipo @stevenbollipo and Dr. Enrik Aguila @enrrikke
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