Extrahepatic portal hypertension in children

Extrahepatic portal vein morphology in children with extrahepatic portal hypertension assessed by 3-dimensional computed tomographic portography: a new etiology of extrahepatic portal hypertension

BACKGROUND/PURPOSE

The cause of extrahepatic portal hypertension in children has not been clarified. Our aim was to determine the morphological features of the extrahepatic portal vein in children with extrahepatic portal hypertension by 3-dimensional computed tomographic portography and to clarify the etiology of this disorder.

MATERIALS AND METHODS

Six patients ranging in age from 10 to 18 years (median age, 12.8 years) who had portal hypertension presented with hematemesis. They underwent intravenous computed tomographic portography using a helical computed tomography scanner and 3-dimensional image reconstruction.

RESULTS

The extrahepatic portal vein was visualized in all patients by 3-dimensional computed tomographic portography. None of the patients showed extrahepatic portal vein obstruction or cavernous transformation. All patients had a tortuous eta-shaped extrahepatic portal vein, and a line could be drawn through the flexures of the portal vein to the hepatic hilum.

CONCLUSION

In children, extrahepatic portal hypertension is not caused by extrahepatic portal vein obstruction and may be of embryological origin.

Portal hypertension in children--the changing spectrum

This report is an analysis of changing trends in the etiology and management of portal hypertension (PHT) in childhood. The study compared the 53 admissions to the Royal Children's Hospital from 1971 to 1991 (33 intrahepatic, 20 extrahepatic) with the 77 admissions (22 intrahepatic, 54 extrahepatic, 1 with a congenital anomaly of the mesenteric vein) from the previous 23-year period (1948 to 1971). In addition to the differences in etiology, there has been (1) an increasing role for sclerotherapy as a therapeutic modality (and with this, lessening of the role of surgery), (2) a different approach to investigation (particularly imaging techniques), and (3) the availability of organ transplantation.

Congenital abnormalities associated with extrahepatic portal hypertension

Congenital abnormalities were present in 12 out of 30 (40%) children with extrahepatic portal hypertension of unknown cause, but in only 2 out of 17 (12%) children with extnahepatic portal hypertension secondary to umbilical vein catheterization or omphalitis. The most frequent abnormalities in this series and in published reports were atrial septal defect, malformation of the biliary tract, and anomalous inferior vena cava. These findings are consistent with the view that some cases with extrahepatic portal hypertension are congenital in origin.

Management of extrahepatic portal hypertension in children

Among 69 patients with PVT, 338 variceal bleeding episodes occurred. Only two patients died from bleeding, and both lived in remote communities and were inaccessible to medical care. Fifty-three children underwent 164 operations for the management of PVT. Once operative management was undertaken, subsequent operations frequently were necessary. Nonoperative measures controlled acute variceal hemorrhage in most instances during the past 10 years. Almost all patients who underwent splenectomy alone, variceal ligation, gastric division, splenic transposition, or makeshift shunts subsequently rebled. These operations are rarely indicated in the current management of children with PVT. Portal venography is essential to define the portal venous circulation before a shunt operation is attempted. Cavomesenteric or central splenorenal shunts prevented further bleeding in eight of 15 patients and are the most reliable operations to control bleeding in patients with PVT. Emergency operation is rarely necessary to control bleeding. Sixteen patients (average age 14.6 years) with PVT did not undergo any operations, and are alive. Each of the six patients with PVT who died from complications of portal hypertension did so within nine months of an operation. Four of these patients had previous splenectomy and died with sepsis as one of the major factors. Bleeding episodes became less frequent as the patients increased in age. Patients who underwent shunts under unfavorable circumstances or who received various other operations to treat portal hypertension appeared to have a higher risk of morbidity and mortality than those managed nonoperatively.