Patients with liver disease present a complication known as esophageal varices. It occurs as a consequence of an ill liver, and blood doesn’t have an adequate flow through it (there is poor circulation within it). Blood looks for alternative ways and goes to the esophagus.

The regular esophagus veins dilate and cause varices. The sicker the liver, the more pressure there will be on varices, and the time comes when the wall bursts and causes bleeding that is usually massive. This bleeding is dangerous for the patient and potentially life-threatening.

It depends on whether or not they are bleeding, or if they had previously bled or not. I will explain each case.

• Patients who have varicose veins but have never bled:
  In these patients, there are two valid options.
  Traditionally, only a medication called propranolol was given to prevent bleeding from varicose veins. This medicine is to lower blood pressure, but it manages to lower the pressure of varices and this reduces the possibility of bleeding.

Other antihypertensive medications do not fulfill the protective function that propranolol provides.
More recently, ligation of varices in people who have never bled is an effective and safe measure to prevent bleeding, and there is a tendency to do it preventively when varicose veins are medium or large.

In my practice, this is my approach with patients. I think it is better to remove or reduce varices, so we solve the main problem, it has also been shown to be very safe.

Propranolol is usually administered in addition to ligation for added safety.

If a patient does not tolerate propranolol, the varicose ligation program should be started, even if there is no bleeding, the medical criteria are clear and uniform in this regard.
Once the ligation process has started, more sessions should continue until the varicose veins disappear or are very small.

• Patients who are bleeding from varices:
  This is one of the most serious complications that a patient with liver disease can present. The patient has massive vomiting of blood and is at risk of death from bleeding. It must be treated immediately.}

A gastroscopy is performed, the point where the bleeding occurs (where the varicose has a hole) is located and a garter is placed at that point. With that, the bleeding stops. Garters are then placed in the other visible varices and the patient is kept under hospital observation until he is considered stable.

Then it is important to continue with more ligation sessions until varicose veins are eliminated.

• Patients who have already bled from varicose veins, once the emergency is over:
  They must prevent further bleeding through an esophageal varicose ligation program that is carried out regularly until the varicose veins disappear or are small.
  Sessions are repeated every 4 to 6 weeks until it is achieved. Usually, in two or three sessions the objective is achieved.

An endoscope is used to visualize the esophagus, varicose veins are located, and the points where they are larger are chosen. Then the garter device is placed on the tip which is like a clear cup with garters around it. The doctor places himself on the varicose vein, sucks it into the cup (the catch), and then releases the garter (a tiny rubber band) with that the varicose vein is tied (hanged) and blood no longer passes through it.

Over the days, the tissue dies due to lack of oxygenation of the blood and the varices disappears, leaving an ulcer that then heals. A scar forms where a vein used to grow and the varicose vein disappears. The garter falls off within days and is expelled by the digestive system.

It can be compared with the not very pleasant procedure of tying the tail of an animal so that it falls and does not grow anymore.
A correct ligation is not just once and now. A program should be started in which appointments are given every 1-2 months to repeat the ligation sessions until the varicose veins disappear or are very small.
The ligation usually generates pain in the central part of the patient’s chest. It is managed with pain relievers such as acetaminophen (which is a safe drug to use in these patients).

Except for the chest pain already mentioned, none is frequent.
There may be bleeding from a loose league or an ulcer at the ligation site. Drilling is possible but highly unlikely.
In our experience, it is very safe and we have never had any complications in our patients.

We always offer the possibility of referring patients to the CCSS, since being a high-risk procedure, performing it in a hospital is slightly more advantageous than in a clinic.
However, to this day, our experience is very satisfactory.

The first time he did patient ligatures was in 2003. Since then it is a regular and almost routine procedure for him.

It is almost routine because he has done it many times, but it is complex and potentially risky. Whenever done, it is performed with the greatest possible care. Adequate follow-up is provided to the patient.

When Dr. Navarro began working at the Hospital San Rafael de Alajuela, the patients at that center did not have this option; they treated the problem with injections of sclerotherapy, which is the old alternative for esophaegal varices.

Dr.Navarro managed the purchase of ligation devices for the first time in Alajuela. He began the protocols of a varicose ligation program with the patients of the Liver Consultation and with patients who come bleeding to the ER.

This program continues to this day, it was continued by colleagues after doctor left the CCSS in 2011. During those years, the ligatures were multiple times each month.