Rare cause of dysphagia after esophageal variceal banding: A case report

Lindsay A Sobotka, Mitchell L Ramsey, Michael Wellner, Sean G Kelly

Abstract

Key words: Case report; Esophageal varices; Band ligation; Esophageal necrosis;Esophageal obstruction

INTRODUCTION

Esophageal and gastric varices are a result of progressive liver disease and portal hypertension. Screening and management of varices is a crucial part of the management in patient with end stage liver disease. Treatment can be performed with band ligation versus non-selective beta blockers depending on the size of varices,ability to tolerate medications and history of esophageal variceal bleeding. Variceal band ligation is a safe and effective intervention for varices with rare but serious complications including bleeding, ulcers and rarely obstruction[1-4].

We present a case of complete esophageal obstruction and necrosis as a result of esophageal variceal banding. The case report explores the differential diagnosis of dysphagia after band ligation, diagnosis of obstruction and reviews potential treatment options.

CASE PRESENTATION

Chief complaint

An 89 years old woman presented with an inability to swallow one day after band ligation of esophageal varices.

History of present illness

The patient experienced almost immediate regurgitation after any oral intake on the way home from endoscopy. Her initial esophagogastroduodenoscopy (EGD) was performed for surveillance of varices. She was found to have large, non-bleeding esophageal varices and type 1 gastroesophageal varices. Two bands were placed on the esophageal varices in the lower esophagus in an upward spiral motion for primary prophylaxis and varices were completely eradicated. She reported feeling well in recovery after the procedure and was discharged.

History of past illness

She has a past medical history of nonalcoholic steatohepatitis cirrhosis.

Physical examination

Upon arrival to the hospital the day after endoscopy, her vital signs were stable. The patient appeared uncomfortable and was not able to tolerate her oral secretions. Her physical exam was otherwise unremarkable with pertinent negatives including ascites, hepatic encephalopathy, hepatosplenomegaly, lower extremity edema or crepitus.

Laboratory abnormalities

Initial blood work revealed a Model of End Organ Liver Disease score of 7. The rest of her blood work was unremarkable including a complete blood count, chemistry and liver function tests. She underwent a chest X-ray, which did not reveal any acute abnormalities.

Further diagnostic workup and interventions

She was treated symptomatically with sublingual nitroglycerin for esophageal spasm,which is a known complication after esophageal banding and was the presumed issue here. She failed to improve with intravenous fluids and conservative management for several days and, therefore, underwent an EGD for further evaluation. Images from endoscopy five days after initial band placement are shown in Figure 1. Endoscopy revealed the mucosa surrounding the banded varix was now necrosed and blocking the lumen of the esophagus.

FINAL DIAGNOSIS

Complete esophageal obstruction and necrosis due to esophageal variceal band ligation.

TREATMENT

The band was purposefully dislodged, revealing distal ulceration and stricturing which could not be transversed with an endoscope. She underwent a computed topography of the chest which did not reveal perforation. Surgery evaluated the patient and did not feel that an operation was warranted. Subsequent gastrograffin swallow study revealed passage of contrast into the stomach without extravasation(Figure 2). Within 72 h after the procedure, she was tolerating an oral diet and was discharged home.

2)廠級數據中心建設以報表管理中心的重點建設作為一個切入口，按照系統規劃，分步實施，分階段推進的方式，分兩期開展，一期主要是通過工廠數據報表中心建設，實現數據的統一匯總、集中展示、分級查詢，實現真正的“數入一庫、數出一門”；二期將結合企業各部門管理需求，開展大數據建模和數據分析建設，實現各類數據的深度關聯和挖掘、完成數據建模，為企業各類決策分析提供依據和支撐。

OUTCOME AND FOLLOW-UP

She returned as an outpatient for an EGD two weeks after discharge. Endoscopy revealed intrinsic moderate stenosis 34 cm from the incisors. The stenosis was 8 mm in diameter by 1 cm in length and dilated with a through-the-scope balloon (Figures 3 and 4).

DISCUSSION

Band ligation is one of the most effective interventions for the prevention and treatment of esophageal variceal hemorrhage. When esophageal varices are banded,local venous occlusion and thrombosis leads to tissue necrosis at the site of the band.The band subsequently sloughs off within about 72 h of placement and a small ulceration is left at the place of the band[2]. Varices subsequently become smaller in diameter, reducing risk of life-threatening bleeding. Patient typically require multiple treatments in order to completely eradicate varices[5].

Variceal banding is an effective and well tolerated procedure; however, side effects including dysphagia, ulcer bleeding, pneumonia, and strictures have been reported[6,7].The prevalence of these side effects, including dysphagia, have been reported in the literature; however rates have varied significantly from 0 to 75% of affected patients[8].Dysphagia after variceal banding is more commonly due to dysmotility and esophageal spasms after banding. These symptoms tend to be transient and typically last about 24 to 48 h and most patients can successfully advance their diet[9]. Rarely dysphagia is a result of complete esophageal obstruction and necrosis. To our knowledge, there has only been 8 cases reports in the literature highlighting the diagnosis and management of this complication[10-18]. While the exact cause of obstruction and factors that predispose patients to developing this are unknown,some authors postulate that obstruction after banding may occur if a band is placed too close to mucosa that is already edematous or necrotic, which can be seen after previous banding[3].

Figure 1 Necrosed esophageal varix causing complete esophageal obstruction.

Given the rarity of this complication, management has been based upon previous case reports in the literature and therefore has varied. Many patients were treated conservatively with no oral intake and received total parental nutrition until symptoms resolved. According to previous case reports, this has been a successful intervention and most patients began to show signs of improvement within a week[2,10-12]. Other case reports have highlighted removing the band endoscopically with mixed outcomes. Endoscopists have attempted band removal with biopsy forceps and rat tooth forceps. While many patients tolerated removal, were able to advance their diet and be discharged from the hospital faster, one patient suffered an intramural esophageal dissection and bleeding[16]. We opted to remove the band with biopsy forceps and this intervention was successful with no complications. Patient was able to safely advance her diet within 24 h. Our patient improved quickly once the band was removed from the obstructing varix, suggesting this could be an ideal intervention if the endoscopist is able to safely perform this maneuver.

CONCLUSION

In conclusion, complete esophageal obstruction and localized necrosis is an extremely rare complication of variceal banding. This should be considered in any patient that presents with an inability to tolerate an oral diet after band ligation of esophageal varices. Diagnosis of this complication is typically with a barium esophagram or repeat upper endoscopy. Treatment may consist of supportive care and nothing by mouth until symptoms resolve or with removing the band endoscopically.

Figure 2 Barium esophagram after band removal.

Figure 3 Esophageal stenosis after band removal.

Figure 4 Balloon dilation of esophageal stenosis.