Ligation of a Bleeding Colonic Varix using an Upper Gastrointestinal Endoscope

Table of Contents

Although anorectal and colonic varices are not uncommon, bleeding from these varices is extremely rare [1] [2] [3]. However, when they do bleed, the bleeding may be massive and occasionally fatal [4]. Endoscopic variceal ligation (EVL) is a well-established procedure for emergency as well as elective ligation of esophageal varices. Although there have been a few reports of variceal ligation to arrest rectal variceal bleeding [5], there have been no reports of its use in bleeding colonic varices, so far as we are aware.

A 32-year-old man was admitted to hospital for massive lower gastrointestinal bleeding. He was known to have cirrhosis of the liver due to hepatitis B and had undergone endoscopic variceal ligation (EVL) for bleeding from esophageal varices. Repeated EVL procedures had led to obliteration of the esophageal varices 9 months prior to this admission. He later developed bleeding from gastric varices, which was effectively controlled, and the gastric varices were obliterated after glue injection.

Intravenous fluids were administered and four units of whole blood were transfused. A bolus of intravenous somatostatin was administered in the other arm, followed by a continuous infusion. With the patient hemodynamically stable, colonoscopy was carried out, and a severely bleeding varix was observed in the descending colon, close to the splenic flexure. During withdrawal of the colonoscope, blood and clots were sucked out. At the same time, an assistant loaded the multiple-band ligation device on a forward-viewing upper gastrointestinal endoscope. Three of the O-rings were fired outside the patient. As soon as the colonoscope was withdrawn, the upper gastrointestinal endoscope with the loaded barrel containing three O-rings was advanced from the rectum as far as the site of bleeding. The bleeding varix was identified (Figure [1]) and sucked into the barrel of the ligation device, and the O-rings were fired. The very first O-ring was successful in ligating the varix, and the bleeding stopped. Another O-ring was applied over the varix (Figure [2]), and the procedure was concluded.

Figure 1 The bleeding colonic varix has been targeted through the ligating device mounted on an upper gastrointestinal endoscope.

Figure 2 The colonic varix has been banded and hemostasis achieved.

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References

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