Endoscopic Variceal Band Ligation (EVL) — Treating and Preventing Variceal Bleeding
Variceal bleeding is the most dangerous acute complication of cirrhosis. Without treatment within hours, mortality exceeds 20% per episode. Endoscopic variceal band ligation (EVL) is the standard of care — it controls active bleeding in over 90% of cases, and a planned eradication programme eliminates the risk of re-bleeding from treated varices. I am Dr Chetan Kalal, DM Hepatologist at Gleneagles Hospital Mumbai. This page explains the procedure, when it is done, and what the eradication programme involves.
What Is EVL?
Esophageal varices are dilated submucosal veins in the lower oesophagus that develop when portal pressure is high enough to open porto-systemic collateral channels. Band ligation places small rubber bands directly over each varix through an endoscope fitted with a multi-band ligator device. The band strangulates the varix, cutting off its blood supply. Over 5–10 days, the varix scleroses and falls off, leaving a small mucosal ulcer that heals. The procedure is repeated at 2–4 week intervals until all varices are eradicated — typically 3–4 sessions.
EVL replaced endoscopic sclerotherapy as the first-line endoscopic treatment in the 1990s. It achieves faster eradication with fewer complications than sclerotherapy.
When Is EVL Recommended?
Acute Variceal Bleeding
EVL is performed within 12 hours of presentation (ideally within 6 hours). Combined with vasopressor medications (terlipressin or somatostatin analogues) and prophylactic antibiotics, it controls bleeding in over 90% of patients.
Primary Prophylaxis
For patients with medium or large varices who have never bled — particularly those with red wale marks on varices or Child-Pugh C cirrhosis — EVL is preferred over beta-blockers, or used in combination.
Secondary Prophylaxis
After a first variceal bleed, EVL is combined with non-selective beta-blockers (carvedilol or propranolol) to prevent re-bleeding. This combination halves the re-bleeding rate versus either treatment alone.
What Happens During the Procedure
EVL is performed under IV sedation (midazolam ± propofol) with throat spray anaesthesia. The endoscope — fitted with a transparent cap holding 6–10 bands — is passed into the oesophagus. Each varix is sucked into the cap and a band is deployed. A single session typically places 4–10 bands depending on the number and size of varices. The procedure takes 15–30 minutes. Most patients are monitored for a few hours and discharged the same day or the following morning.
After the procedure: A soft or semi-liquid diet for 5–7 days is recommended while band ulcers heal. Mild chest discomfort or dysphagia is common for a few days and resolves spontaneously. Avoid NSAIDs and aspirin for 2 weeks (ulcer healing). If you develop severe chest pain or haematemesis after the procedure, contact the hospital immediately.
Eradication Programme and Surveillance
Sessions are repeated every 2–4 weeks until all varices are obliterated (confirmed by endoscopy). After eradication, surveillance endoscopy is performed at 3 months (to confirm eradication), then every 6–12 months thereafter (varices may recur as portal hypertension persists). Beta-blockers are continued long-term after eradication as secondary prevention of new variceal formation.
Risks
EVL is a safe procedure in experienced hands. Band ulcer bleeding (from the mucosal ulcers left after band drop) occurs in approximately 2–5% of sessions and is usually minor. Significant bleeding from an ulcer is rare. Transient dysphagia occurs in up to 15% of patients. Oesophageal stricture is an uncommon late complication, more often associated with sclerotherapy than band ligation.
Book an Endoscopy for Variceal Assessment
If you have cirrhosis and have not had a variceal screening endoscopy, or if you have known varices and need a banding session, contact us to schedule an appointment at Gleneagles Hospital, Mumbai.