How Emergency Endoscopic Band Ligation Controlled a Life-Threatening Variceal Bleed in a Cirrhosis Patient
Patient Profile
| Field | Details |
| Age | 55 years |
| Gender | Male |
| Occupation | Retired government employee |
| City | Pune |
| Presenting Complaint | Sudden onset of large volume vomiting of bright red blood, followed by dizziness, rapid heart rate, and near loss of consciousness |
| Diagnosis | Acute esophageal variceal bleeding secondary to liver cirrhosis with portal hypertension |
| Duration of Issue | Known cirrhosis for two years, no prior variceal screening or prophylactic treatment |
| Previous Treatments | On diuretics for mild ascites, no prior endoscopy or variceal management |
| Date of Procedure | May 2026 |
| Outcome | Excellent, active bleeding controlled during the same endoscopic session, no rebleeding at follow up |
The Problem
Condition
Esophageal varices are dilated submucosal veins in the lower oesophagus that develop as a direct consequence of portal hypertension in patients with cirrhosis. When portal pressure rises beyond a critical threshold, these veins are placed under increasing tension and can rupture suddenly, producing a haemorrhage that is among the most dangerous acute events in gastroenterology. This patient arrived at the emergency department in haemodynamic compromise, having lost a significant volume of blood over a short period at home. He was known to have liver cirrhosis but had never undergone screening endoscopy to assess the presence or grade of varices, meaning this rupture occurred without any prior warning, prophylactic treatment, or established monitoring plan in place.
Emotional & Psychological Impact
For a retired man living with his family, the episode was terrifying for both the patient and those around him. Vomiting blood without warning and losing consciousness briefly at home left his family in a state of acute panic, and he arrived at the emergency department frightened and physically exhausted from the blood loss. He had been aware of his cirrhosis diagnosis for two years but had not been told that variceal bleeding was a specific risk that required active screening and prevention. The gap between knowing he had upper GI bleeding risk and understanding what that risk actually looked like in practice contributed significantly to the shock of the event, both for him and for his family who accompanied him to the hospital.
Consultation & Treatment Plan
What Was Assessed During the Consultation?
- Immediate haemodynamic status including blood pressure, heart rate, and perfusion to establish the urgency and resuscitation requirements before any endoscopic intervention
- Full blood count, coagulation profile, liver function, and renal function to guide transfusion decisions and assess the overall organ reserve ahead of the procedure
- Child Pugh and MELD scoring to classify the severity of the underlying liver disease and guide decisions around antibiotic prophylaxis and vasoactive medication
- Intravenous access, fluid resuscitation, and pharmacological vasoconstriction initiated as bridging measures before the endoscope was introduced
- Urgent upper gastrointestinal endoscopy performed to identify the bleeding source, grade the varices, and deliver definitive endoscopic treatment in the same sitting
Why This Endoscopic Approach Was Chosen
- Dr. Kothari selected emergency endoscopic variceal band ligation as the definitive intervention, combined with pharmacological support, rather than deferring the procedure until the patient was more stable. The reasoning behind this approach included the following points.
- Endoscopic variceal band ligation is the internationally recognised first line treatment for acute variceal haemorrhage, with the highest rate of primary haemostasis and the lowest rebleeding risk among available endoscopic options
- Early endoscopy within twelve hours of presentation is associated with significantly better survival outcomes in cirrhosis related variceal bleeding, making deferral the higher risk option despite the haemodynamic instability
- Vasoactive medication, specifically terlipressin, was initiated before the endoscope was introduced to reduce portal pressure pharmacologically and improve the field of view during the procedure
- Antibiotic prophylaxis was added as a standard adjunct, since cirrhosis patients with acute variceal bleeding have a substantially elevated risk of bacterial infection in the perioperative period, which independently worsens outcomes
Baseline Assessment & Documentation
Haemodynamic parameters, blood work, and endoscopic findings at the time of presentation were documented in full before and immediately after the procedure. This established a clear baseline for monitoring rebleeding risk and planning the secondary prophylaxis program to prevent a further episode.
Management Protocol:- Step by Step
- Intravenous access secured and fluid resuscitation commenced on arrival in the emergency department
- Terlipressin initiated to reduce portal pressure pharmacologically before the endoscopic procedure
- Antibiotic prophylaxis administered as per standard cirrhosis variceal bleeding protocol
- Blood transfusion given to maintain haemoglobin at a conservative threshold to avoid overtransfusion, which can raise portal pressure and worsen rebleeding risk
- Urgent upper gastrointestinal endoscopy performed under sedation, confirming large grade three oesophageal varices with active spurting at one point
- Endoscopic variceal band ligation performed, with multiple bands placed across the bleeding varix and the surrounding high risk vessels in the same session
- Haemostasis confirmed before the scope was withdrawn, and the patient was transferred to a monitored ward bed for close post procedure observation
Management Facts
| Field | Details |
| Setting | Emergency inpatient, monitored ward post procedure |
| Anaesthesia | Conscious sedation for the endoscopic procedure |
| Key Intervention | Endoscopic variceal band ligation with multiple band placement |
| Pharmacological Support | Terlipressin and antibiotic prophylaxis |
| Intraoperative Complications | None, haemostasis achieved in the same session |
| Hospital Stay | Five days for post procedure monitoring and stabilisation |
Post-Management Results
Haemostasis was achieved completely during the endoscopic session, with no rebleeding observed during the five day inpatient stay. The patient’s haemodynamic parameters stabilised within twenty four hours of the procedure, and he was able to tolerate oral intake by day two. Repeat endoscopy was scheduled at two weeks to assess the residual varices and plan the next session of elective band ligation as part of a secondary prophylaxis program to eradicate all remaining high risk vessels.
Outcomes at a Glance
| Outcome Metric | Result |
| Haemostasis | Achieved completely in the same endoscopic session |
| Rebleeding During Admission | None |
| Haemodynamic Recovery | Stabilised within twenty four hours |
| Oral Intake | Resumed by day two post procedure |
| Patient Satisfaction | Very high, grateful for rapid intervention and recovery |
Ongoing Care & Maintenance
Instructions Given to Patient
- Attend all scheduled repeat endoscopy sessions for elective band ligation until variceal eradication is confirmed
- Take prescribed beta blocker medication consistently as secondary prophylaxis to maintain reduced portal pressure between endoscopy sessions
- Follow a low sodium diet and continue diuretic therapy to manage the underlying ascites and reduce portal pressure load
- Avoid all alcohol completely, as even a single episode of heavy drinking can acutely raise portal pressure and precipitate rebleeding
- Report any episode of vomiting blood, black tarry stool, or sudden dizziness immediately and proceed to the emergency department without delay
Monitoring and Follow Up Timeline
| Timeframe | What Patient Could Expect |
| Day 1 to 2 | Haemodynamic monitoring, conservative transfusion, early oral intake resumed |
| Day 3 to 5 | Clinical stability confirmed, discharge planning initiated |
| Week 2 | Repeat endoscopy to assess residual varices and perform elective band ligation |
| Month 1 to 3 | Further elective band ligation sessions until variceal eradication |
| Ongoing | Six monthly surveillance endoscopy and liver function monitoring |
Patient Feedback
“I had no warning at all. One moment I was sitting at home, the next I was vomiting blood and my family was rushing me to the hospital. The doctors acted quickly and by the next day I could already feel the difference. Nobody had ever told me this could happen with my liver condition. Now I understand why the follow up matters so much and I will not miss any appointments.”
Profile: Male, 55 years, Retired government employee, Pune
Procedure: Emergency endoscopic variceal band ligation for acute oesophageal variceal bleeding, Pune, May 2026
Surgeon: Dr. Ksheetij Kothari, Consultant Gastroenterologist
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