Variceal Band Ligation Procedure Note

Note title: Variceal Band Ligation Procedure Note

Date and time of procedure: [Date and time]

Location: [Endoscopy suite / ICU / OR / ED]

Patient name: [Full name]

DOB: [Date of birth]    MRN: [MRN]

Endoscopist: [Name, credentials]

Assistant(s): [Name(s) and role(s)] (Only include if present)

Anesthesia provider: [Name, credentials] (Only include if applicable)

Procedure(s) performed: [EGD with variceal band ligation — esophageal / gastroesophageal junction (GOV1) / both]

Indication and Clinical Context

[Primary indication: acute upper GI bleeding with suspected variceal source / secondary prophylaxis (post-bleed eradication program) / primary prophylaxis (high-risk varices)]. [Relevant clinical context including cirrhosis/portal hypertension history, prior variceal bleeding, hemodynamic status if urgent/emergent]. [Vasoactive infusion and antibiotic status if applicable]. (Include only details relevant to procedural decision-making.)

Diagnoses

Pre-Procedure Diagnosis: [Suspected condition prompting the procedure]

Post-Procedure Diagnosis: [Confirmed findings including variceal characterization, bleeding status, and other significant findings]

Consent and Time-Out

[Informed consent obtained from patient / surrogate / emergent exception pathway]. (If consent cannot be confirmed, do not imply it occurred.)

[Pre-procedure verification and time-out completed, including patient identification, procedure confirmation, allergy review, and antithrombotic status review]. (Only document if completed; otherwise omit or document the applicable exception.)

Sedation and Airway

Sedation/anesthesia: [Topical only / moderate sedation / deep sedation (MAC) / general anesthesia]
Airway status: [Not intubated / intubated pre-procedure / intubated for this procedure]

(If moderate sedation administered by the endoscopist, include the following:)
Medications: [Medication names and doses]
Sedation start: [Time]   Sedation stop: [Time]

(If anesthesia service provided sedation, state: "Sedation provided by anesthesia service; see anesthesia record for details.")

Procedure Details

Extent of examination: [Anatomic extent reached]

Visualization quality: [Adequate / limited due to blood / clots / retained contents / patient intolerance / other]

Banding device: [Device used]   Technical issues: [None / misfires or other issues described]

(If procedure incomplete, state limiting factor and whether repeat endoscopy is planned.)

Non-Variceal Findings

• Esophagus: [Findings or no other significant findings]
• Stomach: [Findings including portal hypertensive gastropathy, gastric varices with classification if present, or no other significant findings]
• Duodenum: [Findings, not examined, or no other significant findings]

Variceal Assessment

Location: [Esophageal varices by segment (upper / mid / lower third) and/or distance from incisors]. [Gastric varices: GOV1 / GOV2 / IGV1 / IGV2 with anatomic specification if present].

Grade/Size: [Small / medium / large] or [F1 / F2 / F3]. (State grading system used.)

High-Risk Stigmata: [Present: red wale markings / red spots / white nipple sign / hematocystic spots] or [Absent]

Bleeding Status at Endoscopy: [No bleeding / suspected recent bleed / oozing / spurting]. (If acute bleeding present, state whether it persisted at start of therapy.)

Source Attribution: [Definite variceal source / presumed variceal source]. (If presumed, document supporting findings and absence of alternative source.)

Band Ligation

• Target: [Esophageal varices / GOV1 / both]
• Bands deployed: [Number attempted]   Bands successfully placed: [Number placed]. (If discrepancy, explain: misfire / dislodgement / poor suction / limited visualization.)
• Placement location: [Distance from incisors and/or segmental locations; describe distal-to-proximal strategy if used]
• Variceal decompression achieved: [Yes / partial / no]
• Hemostasis achieved: [Yes / no / not applicable]
• Adjunctive endoscopic therapy: [Modality, location, and rationale] (Only include if performed.)

Complications and Disposition

Estimated Blood Loss: [Volume in mL]

Complications: [No immediate complications / aspiration / hypoxia / hypotension / perforation / uncontrolled bleeding / band dislodgement / mucosal injury / other]

Disposition: [PACU / ICU / floor]   Airway at conclusion: [Extubated / remained intubated / not intubated]   Hemodynamic status: [Stable / unstable with brief details]

Impression

• [Variceal characterization: location and grade]
• [Bleeding status and hemostasis outcome]
• [Number of bands successfully placed and target areas]
• [Other significant findings affecting management] (Only include if present.)

Post-Procedure Plan

Diet and Precautions: [NPO duration and diet advancement]. [Acid suppression if prescribed]. [Avoidance instructions]. [Red-flag symptoms: hematemesis, melena, severe chest pain, fever].

Acute Bleed Management: [Vasoactive therapy and antibiotic continuation plan; escalation plan if rebleeding occurs]. (Only include if indication was acute hemorrhage; reference primary team orders if managed elsewhere.)

Beta-Blocker Coordination: [NSBB plan: initiate / resume / continue / contraindicated]. [Timing and responsible service for titration]. (If banding alone selected for primary prophylaxis, document rationale.)

Repeat Endoscopy: [Next EGD interval, typically every 2–4 weeks for eradication]. [Goal: eradication / temporizing control]. (If interval deviates from standard, document rationale.)

Follow-Up: [Communication with referring provider or primary team]. [Hepatology/GI clinic follow-up timing]. [Pathology follow-up if biopsies taken].

Signature

[Endoscopist name, credentials]    [Signature]    [Date and time]