Band Ligation-Assisted Histologic Surveillance of Barrett's Esophagus in the Setting of Esophageal Varices

CASE REPORT Barrett's esophagus (BE) with esophageal varices (EV) presents a clinical conundrum. Endoscopists tend to refrain from sampling in such cases due to bleeding risk. We report a biopsy sampling method for the diagnosis and surveillance of BE in the setting EV. Case 1: a 67-year-old man with primary sclerosing cholangitis-related cirrhosis with known EV requiring band ligation, Crohn's disease, and histologically confirmed long-segment BE. Case 2: a 56-year-old man with alcoholic liver cirrhosis and a long-segment salmon-colored mucosa (not sampled during previous endoscopy). The salmon-colored mucosa was C10M12 and C8M9 in each patient, respectively, per the Prague criteria. Large columns of EV were seen in the mid and lower esophagus during endoscopy. A thorough high-definition white-light and narrow band imaging examination did not reveal any nodularity or visible abnormalities. Endoscopic band ligation was performed at the gastroesophageal junction and distal esophagus (3-4 bands were placed). After removing the band ligation kit, the endoscope was reinserted and mucosal samplings using pediatric forceps were obtained from the tip of banded areas (Video 1). There was no immediate or delayed bleeding complication. Pathological examination confirmed nondysplastic BE in both patients. The first and second patients underwent 1 and 2 further surveillance examinations, respectively, with biopsies obtained following the same methodology (to expand the surface area of histologic surveillance), with pathology revealing nondysplastic BE. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_cwxcaaod"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Implementing the Seattle biopsy protocol is challenging when EV are present due to bleeding risk, especially in long segment BE. As an alternative strategy, obtaining biopsies using pediatric forceps from banded areas of esophageal varices is reasonable, feasible, and likely safe for diagnosis and surveillance of BE, understanding the sampling surface area is much smaller. This is particularly important in cases of suspected dysplastic area in the setting of large varices since histologic dysplasia confirmation determines further management of BE. DISCLOSURES Author contributions: F. Hamo, H. Patel and S. Samo.—Study concept and design, acquisition, drafting the manuscript, and critical revision of the final manuscript. P. Nathani, N. Talaat—Critical revision of the final manuscript. S. Samo is the Guarantor of the article. Financial disclosure: None to report. Conflict of Interest: F. Hamo, H. Patel, P. Nathani, N. Talaat: none. S. Samo: Speaker's bureau- Castle Biosciences, Evoke, Medtronic, Merit, Phathom, Sanofi, Takeda. Advisory board- Castle Biosciences, Sanofi. Previous presentation: This submission was presented as a poster at the American College of Gastroenterology Annual Meeting in Vancouver, Canada in 2023. Informed consent was obtained for this case report.