Journal zyxwvutsrq of Gastroenterology and Hepatology zyxwvutsr (1994) zyxwvuts 9, 659-662 zyxwvuts CASE zyxwv REPORT Oesophageal perforation following endoscopic variceal ligation and balloon tamponade MING-CHIH HOU, HAN-CHIEH LIN, FULL-YANG CHANG, FA-YAUH LEE, TSENG-SHING CHEN AND SHOU-DONG LEE Division of Gastroenterology, Department of Medicine, Veterans General Hospital- Taipei, Taipei, Taiwan, Republic of China Abstract Endoscopic variceal ligation (EVL) related complication is rarely reported. A case is presented of a 74 year old man with oesophageal variceal bleeding who developed oesophageal perforation following EVL and balloon tamponade. An oesophageal wall defect was induced by EVL and tissue repair was hindered by decompensated liver reserve and shock status; concomitant balloon tamponade precipitated oesophageal perforation. The case is reported to draw attention to oesophageal perforation after concurrent use of balloon tamponade and EVL. zyxwvu Key words: balloon tamponade, oesophageal perforation, oesophageal variceal ligation. INTRODUCTION Although endoscopic variceal sclerotherapy (EVS) is widely used to treat variceal bleeding, it is associated with a high complication rate ranging from 20 to 40%.’y2 Since 1986 when oesophageal variceal ligation (EVL) was introdu~ed,~ several clinical trials have demonstrated that EVL is as good as EVS in controlling acute bleeding and preventing rebleeding.4-6 Notably, EVL has a lower complication rate compared with that of EVS.4-6 We have used EVL to treat variceal bleeding for more than 400 sessions. The efficacy of controlling and preventing variceal bleeding and the number of sessions needed for variceal eradication are similar to the study by Stiegmann.4 Recently, one case of oesophageal perfora- tion occurred following EVL and balloon tamponade. To our knowledge, no similar case has been reported yet in English literature. Therefore, we present this case to discuss the possible mechanisms. CASE REPORT A 74 year old man was diagnosed as having had liver cirrhosis for 10 years. He visited our hospital because of hematemesis and melaena. A decompensated liver reserve (Child-Pugh’s class C)’ was found. Emergent upper gas- trointestinal endoscopy disclosed active bleeding from oe- sophageal varices (EV). Immediately, EVL was carried out with an overtube, a GIF-XQ2O endoscope (Olyrnpus, Tokyo, Japan) and a ligating device (Bard International, Inc., Tewksberry, MA, USA) to arrest active bleeding. It was performed as the following procedures: EV were ligated from the gastro-oesophageal junction (GEJ) up to 5 cm above the GEJ. Each column of varix was ligated with 1-2 rubber bands according to the variceal size. In total, eight rubber bands were used in this session. One week later, endoscopy revealed some retained rubber bands and extensive ulceration on the EV (Fig. I), so the second session of EVL was delayed. During this period, he remained well until midnight of the 10th day when rebleeding and hypotensive shock occurred. Because immediate endoscopic haemostatis was unavailable, re- suscitation was initiated and octreotide (Sandostatin, Sandoz Pharmaceutical Ltd, Taiwan, ROC) was infused using a schedule previously prescribed? Initial control of bleeding failed, so a 4-lumen Sengstaken-Blakemore (SB) tube (Rusch UK Ltd., Buckinghamshire, UK) was smoothly inserted; however, he suffered from epigastric discomfort and chest distress when the gastric balloon was inflated, so the tube was removed immediately. At the same time, EV bleeding ceased spontaneously. Unfor- tunately, shortness of breath developed soon after, so an endotracheal tube was inserted. The chest roentgeno- gram (Fig. 2) revealed oesophageal perforation, which was confirmed by computerized tomography scan (Fig. 3). A chest tube was inserted and a pleural effusion exam- ination showed empyema formation. Because of his poor surgical risk, the patient was on total parenteral nutrition and antibiotic therapy. Two weeks after the Correspondence: Dr S-D. Lee, Division of Gastroenterology,Department of Medicine, Veterans General Hospital-Taipei, Taipei Accepted for publication 21 April 1994. 112, Taiwan, Republic of China.