Scientific letters
Aphagia following esophageal variceal ligation
Afagia post banding esofágico
Andrés Wonaga
, Carolina Ozollo-Landa, María Marta Piskorz, Carlos Waldbaum, Juan Sordá
Corresponding author
Division of Gastroenterology, Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
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array:4 [ "nombre" => "Andrés" "apellidos" => "Wonaga" "email" => array:1 [ 0 => "awonaga@yahoo.com.ar" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Carolina" "apellidos" => "Ozollo-Landa" ] 2 => array:2 [ "nombre" => "María Marta" "apellidos" => "Piskorz" ] 3 => array:2 [ "nombre" => "Carlos" "apellidos" => "Waldbaum" ] 4 => array:2 [ "nombre" => "Juan" "apellidos" => "Sordá" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Division of Gastroenterology, Hospital de Clínicas José de San Martín, Buenos Aires, Argentina" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Afagia post banding esofágico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 814 "Ancho" => 990 "Tamanyo" => 133809 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">It is observed that a band takes all the circumference of the esophagus and causes a total esophageal obstruction.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Most of the cirrhotic patients develop portal hypertension in the course of the disease. It is estimated that esophageal varices are present in more than 30% of patients with compensated cirrhosis and approximately 60% with decompensated cirrhosis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The most important predictive factors of the variceal bleeding are the severity of the liver dysfunction (Child B-C), large variceal size and the presence of the red wale marks. The current consensus suggests that an endoscopy for variceal screening should be performed to every patient who is diagnosed with cirrhosis. This recommendation is made to identify which group of patients needs prophylaxis treatment.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> For the prevention of first variceal hemorrhage, in patients with cirrhosis and small varices with red wale marks or Child–Pugh C, nonselective beta-blockers should be used but in patients with medium–large varices nonselective beta-blockers or Endoscopic Variceal Ligation (EVL) may be recommended. EVL is a safe technique for the treatment of acute variceal bleeding and for the primary prevention of hemorrhage and rebleeding in patients who suffer from portal hypertension, considering sclerotherapy an alternative endoscopic method.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report a case of a 65-year-old woman with a medical history of Child–Pugh A cirrhosis owing to hepatitis C virus and no hepatic decompensation who had large esophageal varices secondary to portal hypertension. The patient stopped beta-blockers due to side effects. She had three sessions of EVL. Two days after the third session, she went to hospital because she had vomits at home after the banding procedure. Those vomits persisted despite the administration of prokinetics. The patient was lucid, afebrile, haemodinamically stable and with normal oxygen saturation. Therefore, it was decided to perform an upper endoscopy. Food debris and a total esophageal obstruction were found in the lower third of the esophagus due to a band wrapping the entire circumference and causing ulcerated mucosa in that place (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In order to unblock the esophagus, we tried to push down and carefully remove the band with forceps without any success (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). We adopted expectant behavior and decided to hospitalize the patient in a medical clinic room and start the intravenous hydration. Forty-eight hours later, the patient was able to swallow liquids, so the next day a follow-up endoscopy was performed observing a circumferential ulcer and stricture formation, which was gently passed with the endoscope (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). She was discharged from hospital and a month later the study was repeated with no residual lesion.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">EVL complications are at a rate lower than 15% and include: ulcers, transient dysphagia, chest pain, bleeding, stricture formation and infections. The first case of aphagia after an EVL was reported by Saltzman and Arora in 1993. The aphagia was not caused by a unique band, but by the newly banded varices that completely obstructed the esophageal lumen. The obstruction was resolved by pushing away the bands with an endoscope twenty-four hours after the procedure.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> So far, we have found four cases published like ours.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–9</span></a> Saftoiu et al. reported the first case. Forty-eight hours after the ligation, they observed the obstruction and managed to unblock the esophagus pushing softly. In a similar case, Verma et al. repeated the endoscopy without trying to dislodge the obstruction. They adopted a wait-and-see approach and a week later the patient could eat food. Nikoloff et al. do not suggest performing the endoscopy owing to a bleeding risk but they recommend contrast swallow studies and watchful waiting until their patient could swallow liquids. In their case, the patient was able to swallow liquids seven days after the ligation. Chahal et al. performed an endoscopy using forceps to unblock the obstruction. However, they had to stop the procedure due to a small amount of bleeding. In our case, we decided to perform an endoscopy, tried to push and carefully remove the band with forceps. As the endoscope could not pass, we adopted expectant behavior. Forty eight hours later the patient was able to swallow liquids (four days after the ligation). Factors that could be present in a situation like this are: technical defect, edema, the size of the band and a ball-valve effect (when the varix is banded, near a previous banding stricture).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In all the cases that a watchful waiting approach was adopted, the medical evolution was good and it was probably the best way to proceed.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors have not received any funding or benefits from industry or elsewhere to conduct this study.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors have not declared any conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 814 "Ancho" => 990 "Tamanyo" => 133809 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">It is observed that a band takes all the circumference of the esophagus and causes a total esophageal obstruction.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 589 "Ancho" => 1300 "Tamanyo" => 121809 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) It is intended to unblock the esophagus with the use of forceps. (B) Four days after the banding, a circumferential ulcer and a stricture formation are observed.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Betablockers to prevent gastroesophageal varices in patients with cirrhosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.J. Groszmann" 1 => "G. Garcia-Tsao" 2 => "J. Bosch" 3 => "N.D. Grace" 4 => "A.K. Burroughs" 5 => "R. 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Schreibman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Gastroenterol Hepatol" "fecha" => "2011" "volumen" => "7" "paginaInicial" => "557" "paginaFinal" => "559" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complete esophageal obstruction following endoscopic variceal band ligation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H. Chahal" 1 => "A. Ahmed" 2 => "C. Sexton" 3 => "A. Bhatia" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "J Community Hosp Intern Med Perspect" "fecha" => "2013" "volumen" => "3" "paginaInicial" => "1" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complications of esophageal variceal band ligation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.R. Saltzman" 1 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 0 | 8 |
| 2024 October | 24 | 2 | 26 |
| 2024 September | 34 | 2 | 36 |
| 2024 August | 28 | 5 | 33 |
| 2024 July | 17 | 5 | 22 |
| 2024 June | 24 | 4 | 28 |
| 2024 May | 28 | 2 | 30 |
| 2024 April | 22 | 2 | 24 |
| 2024 March | 42 | 8 | 50 |
| 2024 February | 27 | 4 | 31 |
| 2024 January | 70 | 5 | 75 |
| 2023 December | 48 | 3 | 51 |
| 2023 November | 45 | 11 | 56 |
| 2023 October | 72 | 4 | 76 |
| 2023 September | 52 | 1 | 53 |
| 2023 August | 41 | 0 | 41 |
| 2023 July | 60 | 4 | 64 |
| 2023 June | 44 | 3 | 47 |
| 2023 May | 58 | 0 | 58 |
| 2023 April | 61 | 2 | 63 |
| 2023 March | 58 | 4 | 62 |
| 2023 February | 46 | 7 | 53 |
| 2023 January | 44 | 24 | 68 |
| 2022 December | 37 | 14 | 51 |
| 2022 November | 53 | 20 | 73 |
| 2022 October | 39 | 15 | 54 |
| 2022 September | 34 | 24 | 58 |
| 2022 August | 32 | 11 | 43 |
| 2022 July | 24 | 14 | 38 |
| 2022 June | 24 | 13 | 37 |
| 2022 May | 15 | 9 | 24 |
| 2022 April | 19 | 11 | 30 |
| 2022 March | 36 | 11 | 47 |
| 2022 February | 16 | 11 | 27 |
| 2022 January | 24 | 13 | 37 |
| 2021 December | 22 | 11 | 33 |
| 2021 November | 26 | 6 | 32 |
| 2021 October | 37 | 11 | 48 |
| 2021 September | 31 | 10 | 41 |
| 2021 August | 26 | 8 | 34 |
| 2021 July | 20 | 11 | 31 |
| 2021 June | 30 | 7 | 37 |
| 2021 May | 25 | 10 | 35 |
| 2021 April | 69 | 17 | 86 |
| 2021 March | 52 | 14 | 66 |
| 2021 February | 39 | 11 | 50 |
| 2021 January | 43 | 21 | 64 |
| 2020 December | 30 | 9 | 39 |
| 2020 November | 25 | 5 | 30 |
| 2020 October | 16 | 10 | 26 |
| 2020 September | 23 | 8 | 31 |
| 2020 August | 23 | 6 | 29 |
| 2020 July | 25 | 4 | 29 |
| 2020 June | 15 | 12 | 27 |
| 2020 May | 13 | 6 | 19 |
| 2020 April | 15 | 4 | 19 |
| 2020 March | 20 | 8 | 28 |
| 2020 February | 23 | 6 | 29 |
| 2020 January | 19 | 6 | 25 |
| 2019 December | 36 | 11 | 47 |
| 2019 November | 12 | 13 | 25 |
| 2019 October | 15 | 4 | 19 |
| 2019 September | 19 | 12 | 31 |
| 2019 August | 13 | 4 | 17 |
| 2019 July | 30 | 21 | 51 |
| 2019 June | 49 | 47 | 96 |
| 2019 May | 129 | 73 | 202 |
| 2019 April | 56 | 64 | 120 |
| 2019 March | 8 | 9 | 17 |
| 2019 February | 14 | 14 | 28 |
| 2019 January | 10 | 5 | 15 |
| 2018 December | 6 | 9 | 15 |
| 2018 November | 13 | 6 | 19 |
| 2018 October | 18 | 15 | 33 |
| 2018 September | 4 | 0 | 4 |
| 2018 August | 12 | 4 | 16 |
| 2018 July | 10 | 0 | 10 |
| 2018 June | 6 | 4 | 10 |
| 2018 May | 9 | 11 | 20 |
| 2018 April | 4 | 4 | 8 |
| 2018 March | 2 | 5 | 7 |
| 2018 February | 9 | 3 | 12 |
| 2018 January | 3 | 4 | 7 |
| 2017 December | 8 | 4 | 12 |
| 2017 November | 8 | 2 | 10 |
| 2017 October | 6 | 2 | 8 |
| 2016 October | 1 | 0 | 1 |
| 2016 April | 1 | 0 | 1 |
| 2016 March | 1 | 0 | 1 |
| 2016 February | 1 | 0 | 1 |
| 2016 January | 1 | 1 | 2 |
| 2015 December | 3 | 1 | 4 |
| 2015 November | 1 | 0 | 1 |
| 2015 October | 8 | 8 | 16 |
| 2015 September | 8 | 4 | 12 |
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