Background: Endoscopic hemorrhoidal ligation may provide an alternative to surgical treatment of internal hemorrhoids. This study assessed the safety and efficacy of endoscopic elastic band ligation for bleeding internal hemorrhoids. Methods: Endoscopic hemorrhoid ligation was performed in 20 adult patients who had chronic rectal bleeding attributed to internal hemorrhoids. Elastic band ligation was accomplished using a ligating device attached to the end of a video endoscope. Repeat endoscopy was done 3 weeks after the initial procedure. Results: Seventy band ligations were performed during 23 separate sessions. Post-therapy endoscopy showed reduction of hemorrhoidal size by at least one grade in 19 of 20 patients (95%). Bleeding resolved in 19 of 20 patients (95%) in 5.4 months (mean) of follow-up; 18 of 20 (90%) required only one banding session. No major complications (perforation, secondary bleeding, deep ulceration) occurred in this small group. Conclusions: Preliminary data indicates that endoscopic hemorrhoidal ligation is a safe and effective technique for treating internal hemorrhoids. It holds promise as an important technique for successfully treating and possibly eradicating symptomatic internal hemorrhoids. (Gastrointest Endosc 1998;48:49-52.)