Esophageal varices ligation (EVL)

What is it?

Esophageal varices are dilations of veins in the esophagus typically observed in patients with liver cirrhosis. In fact, a chronically damaged liver causes increased pressure in the vein that carries blood from the intestine to the liver (portal vein) resulting in the development of new veins, called collateral vessels, that bypass the liver. These veins develop in various locations, mainly in the distal esophagus where, having become bulging and tortuous, they are subject to rupture with the occurrence of bleeding, which may leak from the mouth (hematemesis) or be eliminated through the intestine, with blackish feces (melena).

The diagnosis is obtained by performing an endoscopic examination (gastroscopy), which also allows treatments, such as ligation of esophageal varices.

When is this exam indicated?

This endoscopic treatment is recommended for any patient suffering from upper gastrointestinal bleeding whose origin is esophageal varices. It is also the therapy of choice in acute bleeding. 

Variceal ligation may also be useful in primary prophylaxis, that is, in preventing the first bleeding of medium or large esophageal varices and for patients with contraindication or intolerance to beta-blocker drug therapy.

How is it performed?

During gastroscopy, it is possible to stop the bleeding by applying a small elastic ring at the base of the varice, which causes a thrombosis of the varice and its subsequent occlusion and disappearance. In order to obtain a complete disappearance of all varices, several endoscopic examinations are necessary (usually from 3 to 5), which are performed weekly or every 2 weeks. The total removal of all varices is important to prevent further bleeding.


After ligation of esophageal varices, fever, difficulty in swallowing, chest pain and/or upper abdominal pain may occur, which resolve spontaneously and should cause concern only upon their continuation.

Ulcers of the mucous membrane of the esophagus may also occur. The fall after a few days of the small crusts that cover them (eschar) can be the cause of new bleeding that generally stops spontaneously.

The difficulty in swallowing tends to disappear after a few days and only its persistence for a long time can indicate the presence of a narrowing of the esophagus consequent to the treatment. This complication can easily be remedied endoscopically.

More serious complications, such as perforation, are much rarer.

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