Extrahepatic portal hypertension: a review of 70 cases

Extrahepatic Portal Vein Obstruction in Children

OBJECTIVES

Extrahepatic portal vein obstruction is the most common cause of portal hypertension in children. This study aimed to evaluate the causes, clinical, laboratory and endoscopic findings, treatment approaches, long-term results, and prognosis of extrahepatic portal vein obstruction in children.

MATERIALS AND METHODS

We retrospectively evaluated 82 patients who were followed up with the diagnosis of extrahepatic portal vein obstruction at Gazi University Pediatric Gastroenterology clinic between January 1, 2011, and October 31, 2021.

RESULTS

Among our patients, 58.5% were male, median age at presentation was 36 months (range, 1 month to 6 years), and the follow-up period was 2 years (range, 1-14 years). The most common reasons for admission were gastrointestinal bleeding and splenomegaly. All patients diagnosed with incidentally detected obstruction were children under 5 years of age. The most frequently detected risk factors were history of umbilical vein catheterization (50%) and presence of procoagulant status (31%). Esophageal varices (94.8%), variceal bleeding (73.2%), hypersplenism (64.6%), and growth failure (13.4%) were the most common complications. Weight and/or height z-scores were lower in children with esophageal varices, variceal bleeding, and hypersplenism. Endoscopic treatments were more frequently applied to those with splenomegaly, thrombocytopenia, red color sign, and esophageal variceal bleeding. Rates of splenomegaly, hypersplenism, esophageal variceal bleeding, advanced varicose veins, and portal biliopathy were higher in patients who underwent portosystemic shunt surgery than in patients who did not undergo it.

CONCLUSIONS

Morbidity and mortality rates of variceal bleeding in extrahepatic portal vein obstruction were lower than bleeding seen in cirrhotic prehepatic portal hypertension. In our study, no patients died from extrahepatic portal vein obstruction-related complications. One patient died from tuberculous meningitis.

Portal hypertension and hypersplenism in extrahepatic portal venous obstruction: Are they related?

BACKGROUND AND AIMS

Portal hypertension (PHT) due to extrahepatic portal venous obstruction (EHPVO) is common in developing countries. Hypersplenism is a near-constant feature of EHPVO, but its significance, unlike in cirrhotics, is unknown. We aimed to study the relationship between hypersplenism and the severity of PHT in patients with EHPVO.

METHODS

This prospective study was done at a tertiary care center from January 2014 to August 2015. All patients with EHPVO who underwent a splenectomy and a shunt or devascularization were included. Data regarding clinical profile, preoperative parameters, and intraoperative details were recorded. The correlation was studied between hypersplenism and the intraoperatively measured portal pressures and markers of PHT.

RESULTS

Of the 40 patients studied (mean [SD] age 22.4 [8.4] years), hematological hypersplenism was present in 39 (97.5%). The mean (SD) hemoglobin, total leukocyte counts (TLC), and platelet counts were 9.9 (2.4) g/dL, 2971 (1239) cells/mm³, and 66,400 (32047) cells/mm³, respectively. The mean (SD) sonographic spleen volume (SV), splenic weight, and intraoperative portal pressure were 1084.7 (553.9) cm³, 1088.7 (454.7) g, and 35.6 (5.1) mmHg, respectively. The TLC and platelet counts correlated inversely with the portal pressure. Additionally, the platelet counts correlated negatively with eradicated variceal status, SV, and weight; hemoglobin with SV and weight; and TLC with SV. Multivariate analysis showed the platelet counts were an independent predictor of portal pressures and platelet counts ≤ 53,500 cells/mm³ indicated significantly high portal pressures.

CONCLUSIONS

The platelet counts showed a significant inverse correlation with portal pressures in patients with EHPVO and may be used as surrogate markers of PHT. A platelet count ≤ 53,500 cells/mm³ is predictive of significantly high pressures.

[Role of splenectomy in the treatment of non-cirrhotic portal hypertension: about 3 cases]

L’hypertension portale non cirrhotique est une affection décrite pour la première fois par Guido BANTI en 1898 comme une affection associant une hypertension portale avec splénomégalie et anémie sur foie sain. Le diagnostic repose sur l’échographie abdominale, la splénoportographie et la biopsie hépatique. Le but de notre travail est d’évaluer la place de la splénectomie dans l’hypertension portale non cirrhotique à travers une étude rétrospective portant sur 3 malades dont 2 femmes et un homme pris en charge dans notre formation entre Janvier 2010 et Septembre 2016. Le diagnostic de l’hypertension portale idiopathique a été basé sur les critères suivants : une hypertension portale, la présence des varices oesophagiènnes avec une splénomégalie, l’absence de cirrhose ou d’autres affections hépatiques responsables de l’hypertension portale. La splénectomie a été réalisée chez les 3 malades. L’évolution après la splénectomie était marquée par la normalisation des signes cliniques, radiologiques et biologiques de cette affection, avec absence de récidive des varices œsophagiennes. La splénectomie associée à la ligature des varices œsophagiennes pourraient être suffisantes pour traiter ce syndrome et surtout ses conséquences sans avoir recours à une dérivation spléno-rénale.

Angiogenesis and portal-systemic collaterals in portal hypertension

In patients with advanced liver disease with portal hypertension, portal-systemic collaterals contribute to circulatory disturbance, gastrointestinal hemorrhage, hepatic encephalopathy, ascites, hepatopulmonary syndrome and portopulmonary hypertension. Angiogenesis has a pivotal role in the formation of portal-systemic shunts. Recent research has defined many of the mediators and mechanisms involved in this angiogenic process, linking the central roles of hepatic stellate cells and endothelial cells. Studies of animal models have demonstrated the potential therapeutic impact of drugs to inhibit angiogenesis in cirrhosis. For example, inhibition of VEGF reduces portal pressure, hyperdynamic splanchnic circulation, portosystemic collateralization and liver fibrosis. An improved understanding of the role of other angiogenic factors provides hope for a novel targeted therapy for portal hypertension with a tolerable adverse effect profile.

Thrombosis in the Neonatal Intensive Care Unit

Neonates have the highest risk for pathologic thrombosis among pediatric patients. A combination of genetic and acquired risk factors significantly contributes to this risk, with the most important risk factor being the use of central venous catheters. Proper imaging is critical for confirming the diagnosis. Despite a significant number of these events being life- and limb-threatening, there is limited evidence on what the appropriate management strategy should be. Evaluation and treatment of any neonate with a clinically significant thrombosis should occur at a tertiary referral center that has proper support.

Advances in the management of childhood portal hypertension

Portal hypertension is one of the most serious complications of childhood liver disease, and variceal bleeding is the most feared complication. Most portal hypertension results from cirrhosis but extra hepatic portal vein obstruction is the single commonest cause. Upper gastrointestinal endoscopy endoscopy remains necessary to diagnose gastro-esophageal varices. Families of children with portal hypertension should be provided with written instructions in case of gastrointestinal bleeding. Children with large varices should be considered for primary prophylaxis on a case-by-case basis. The preferred method is variceal band ligation. Children with acute bleeding should be admitted to hospital and treated with antibiotics and pharmacotherapy before urgent therapeutic endoscopy. All children who have bled should then receive secondary prophylaxis. The preferred method is variceal band ligation and as yet there is little evidence to support the use of β-blockers. Children with extrahepatic portal vein obstruction should be assessed for suitability of mesoportal bypass.

Portal hypertension: A critical appraisal of shunt procedures with emphasis on distal splenorenal shunt in children

Background:

Extrahepatic portal venous obstruction (EHPVO) is the most common cause of pediatric portal hypertension. We analyzed the investigative protocol and results of portosystemic shunts in this group of patients.

Materials and Methods:

A total of 40 consecutive children aged below 12 years operated with a diagnosis of extra-hepatic portal hypertension formed the study group. Historical data and clinical data were collected. All patients underwent upper gastrointestinal endoscopy, ultrasound Doppler and computed tomographic portogram pre-operatively and post-operatively. Results with respect to shunt patency, hypersplenism and efficacy of different radiological investigations were collected.

Results:

A total of 40 patients, 28 boys and 12 girls constituted the study group. Lienorenal shunt (LRS) was performed in 14 patients; distal splenorenal shunt in 21 patients and side-to-side lienorenal shunt in 4 patients, inferior mesenteric renal shunt was performed in 1 patient. Follow-up ranged from 36 to 70 months. At a minimum follow-up of 3 years, 32 (80%) patients were found to have patent shunts. Patent shunts could be visualized in 30/32 patients with computer tomographic portogram (CTP) and 28/32 with ultrasound. Varices regressed completely in 26/32 patients and in the rest incomplete regression was seen. Spleen completely regressed in 19/25 patients. Hypersplenism resolved in all patients with patent shunts.

Conclusions:

Portosystemic shunting in children with EHPVO is a viable option. While long-term cure rates are comparable with sclerotherapy, repeated hospital visits are reduced with one time surgery. Pre-operative and post-operative assessment can be performed with complimentary use of ultrasound, CTP and endoscopy.

Management of bleeding in extrahepatic portal venous obstruction

Extrahepatic portal venous obstruction, although rare in the western world, is a common cause of major and life threatening upper gastrointestinal bleeding among the poor in developing countries. Patients have large spleens and stunted growth. The diagnosis is easily confirmed by Doppler ultrasonography. Endoscopy sclerotherapy is the best option for the control of acute variceal bleeding. For secondary prophylaxis of bleeding, the choice lies between repeated sclerotherapy and a portosystemic shunt. We believe that due consideration should be given to performing a splenectomy and a lienorenal shunt. Performed by experienced surgeons, it carries a low operative mortality of 1%, a rebleeding rate of about 10%, removes the large spleen, reverses hypersplenism, and is not followed by portosystemic encephalopathy. Most importantly, it is a onetime procedure particularly suited to those who have little access to blood transfusion and sophisticated medical facilities.

Management of hypersplenism in non-cirrhotic portal hypertension: a surgical series

BACKGROUND

Hypersplenism is commonly seen in patients with non-cirrhotic portal hypertension (NCPH). While a splenectomy alone can effectively relieve the hypersplenism, it does not address the underlying portal hypertension. The present study was undertaken to analyze the impact of shunt and non-shunt operations on the resolution of hypersplenism in patients with NCPH. The relationship of symptomatic hypersplenism, severe hypersplenism and number of peripheral cell line defects to the severity of portal hypertension and outcome was also assessed.

METHODS

A retrospective analysis of NCPH patients with hypersplenism managed surgically between 1999 and 2009 at our center was done. Of 252 patients with NCPH, 64 (45 with extrahepatic portal vein obstruction and 19 with non-cirrhotic portal fibrosis) had hypersplenism and constituted the study group. Statistical analysis was done using GraphPad InStat. Categorical and continuous variables were compared using the chi-square test, ANOVA, and Student's t test. The Mann-Whitney U test and Kruskal-Wallis test were used to compare non-parametric variables.

RESULTS

The mean age of patients in the study group was 21.81+/-6.1 years. Hypersplenism was symptomatic in 70.3% with an incidence of spontaneous bleeding at 26.5%, recurrent anemia at 34.4%, and recurrent infection at 29.7%. The mean duration of surgery was 4.16+/-1.9 hours, intraoperative blood loss was 457+/-126 (50-2000) mL, and postoperative hospital stay 5.5+/-1.9 days. Following surgery, normalization of hypersplenism occurred in all patients. On long-term follow-up, none of the patients developed hepatic encephalopathy and 4 had a variceal re-bleeding (2 after a splenectomy alone, 1 each after an esophago-gastric devascularization and proximal splenorenal shunt). Patients with severe hypersplenism and those with defects in all three peripheral blood cell lineages were older, had a longer duration of symptoms, and a higher incidence of variceal bleeding and postoperative morbidity. In addition, patients with triple cell line defects had elevated portal pressure (P=0.001), portal biliopathy (P=0.02), portal gastropathy (P=0.005) and intraoperative blood loss (P=0.001).

CONCLUSIONS

Hypersplenism is effectively relieved by both shunt and non-shunt operations. A proximal splenorenal shunt not only relieves hypersplenism but also effectively addresses the potential complications of underlying portal hypertension and can be safely performed with good long-term outcome. Patients with hypersplenism who have defects in all three blood cell lineages have significantly elevated portal pressures and are at increased risk of complications of variceal bleeding, portal biliopathy and gastropathy.

Management of portal hypertension in children

Portal hypertension can be caused by a wide variety of conditions. It frequently presents with bleeding from esophageal varices. The approach to acute variceal hemorrhage in children is a stepwise progression from least invasive to most invasive. Management of acute variceal bleeding is straightforward. But data on primary prophylaxis and long term management prevention of recurrent variceal bleeding in children is scarce, therefore prospective multicenter trials are needed to establish best practices.

A clinical prediction rule and platelet count predict esophageal varices in children

BACKGROUND & AIMS

The validation of noninvasive tests to diagnose esophageal varices is a priority in children because repeated endoscopic evaluations are too invasive. We measured the ability of a previously developed noninvasive clinical prediction rule (CPR) to predict the presence of esophageal varices in children.

METHODS

We analyzed data from 108 children, younger than age 18, who received endoscopies at 8 centers, to assess portal hypertension from chronic liver disease or portal vein obstruction. Blood test and abdominal ultrasound scan results were obtained within 4 months of endoscopy. Grading of varices identified by endoscopy was confirmed by independent blinded review. Spleen size, based on data from the ultrasound scan, was expressed as a standard deviation score relative to normal values for age.

RESULTS

Of the children studied, 74 had esophageal varices (69%), including 35 with large varices (32%). The best noninvasive predictors of esophageal varices of any size were as follows: platelet:spleen size z-score ratio (area under the receiver operating characteristic curve [AUROC], 0.84; 95% confidence interval [CI] 0.75-0.93), CPR (AUROC, 0.80; 95% CI, 0.70-0.91), and platelet count (AUROC, 0.79; 95% CI, 0.69-0.90). The positive predictive values for the CPR and platelet count were 0.87 and 0.86, the negative predictive values were 0.64 and 0.63, the positive likelihood ratios were 3.06 and 2.76, and the negative likelihood ratios were 0.64 and 0.63, respectively. Based on positive and negative predictive values, the most accurate noninvasive tests were the CPR and platelet counts.

CONCLUSIONS

Noninvasive tests such as CPR and platelet count can assist in triaging children for endoscopy to identify esophageal varices.

Neonatal portal vein thrombosis: diagnosis and management

Neonatal portal vein thrombosis (PVT) is an increasingly recognized event. Patients are generally asymptomatic in the neonatal period. The diagnosis is made with Doppler ultrasound. Umbilical catheterization, exchange transfusion and sepsis are risk factors for neonatal PVT. Thrombophilia is possibly a contributing risk factor. Although there are potential serious acute complications such as hepatic necrosis, the outcome is good in the majority of cases, followed up to 8 years of age. Thrombus resolution occurs in 30-70% in days to months. Liver lobe atrophy may occur following PVT, and does not appear to be associated with any impairment of liver function. Non-occlusive thrombosis is more likely to resolve than non-occlusive thrombosis. A subset of patients without resolution is at risk for developing portal hypertension over the next decade of life. There are no current defining features present during the neonatal period to enable identification of neonates at risk for portal hypertension. There is no evidence that anticoagulation therapy improves time to resolution or decreases the likelihood of portal hypertension. Anticoagulation therapy may be considered. A management algorithm is proposed.

Extrahepatic portal venous obstruction: The effects of early ligation of splenic artery during splenectomy

Aim:

To objectively demonstrate the gain in blood volume and blood components following early ligation of splenic artery during splenectomy and splenorenal shunts in children with extra hepatic portal venous obstruction (EHPVO).

Methods:

Twenty-eight children (20 males and 8 females, mean age: 9.9 (±3.2) years) with EHPVO and hypersplenism were recruited. We followed a protocol of systematically locating and ligating the splenic artery first, followed by a 30-minute waiting period to allow the massive spleen to decongest via the splenic vein and venous collaterals and then completing the splenectomy by standard procedure. No intravenous fluid was administered during this 30-minute period. Blood samples were drawn just prior to splenic artery ligation and soon after splenectomy for the estimation of hematological and biochemical parameters.

Results:

We noticed a highly significant increase in the hemoglobin, hematocrit, leukocyte, platelet, and RBC counts by early ligation of the splenic artery (p < 0.0004). The gain in hemoglobin and hematocrit was equivalent to a transfusion of atleast 100-150 ml of packed RBC. The increase in platelet count was equivalent to a platelet transfusion of atleast 4 units of platelet concentrates in an adult. There is a positive correlation between the splenic weight and the platelet gain (p= 0.0568) and the splenic volume on preoperative imaging and the platelet gain (p= 0.0251).

Conclusion:

Early ligation of the splenic artery during splenectomy results in passive splenic decongestion and thereby a significant gain in blood components. This protocol appears to be a feasible blood conservation method to avoid blood transfusions in this group of hypersplenic EHPVO patients.

Childhood outcomes of neonates diagnosed with portal vein thrombosis

AIM

The study aims to determine childhood outcomes of neonates diagnosed with portal vein thrombosis (PVT).

METHODS

A retrospective chart review of neonates diagnosed with PVT who had documented follow up (physical examination, laboratory tests or ultrasonographic examination) at the age of 2 years or beyond was conducted.

RESULTS

Data were available for 70 children (71% of eligible neonates) at a median age of 5 years (range 2-8 years). Physical examination was unremarkable in all who were examined (n= 68). Twenty-five children had liver functions assessed and only mild abnormalities were detected in nine children. Six of 25 patients tested for thrombophilia showed abnormalities. Thirty-seven children had ultrasonographic follow up. Left lobar atrophy (LLA) was noted in 20 children (16 had isolated LLA, two had LLA and splenomegaly, and two had LLA and portal hypertension). Five children who had normal ultrasound examinations at discharge had splenomegaly (two with additional finding of LLA) at follow up. Two children with portal hypertension diagnosed during neonatal period needed porta-caval shunting.

CONCLUSION

Our results show that among patients, who had PVT as neonates, 28% still had asymptomatic LLA in childhood, 7% had slowly progressive splenomegaly and 3% required shunting because of progression of portal hypertension. Ultrasonographic follow up was the most sensitive method in detecting progression associated with neonatal PVT. Until more data are available, periodic long-term ultrasonographic follow up should be considered for neonates diagnosed with PVT.

Variation in care for children with esophageal varices: a study of physicians', patients', and families' approaches and attitudes

BACKGROUND AND AIMS

Inadequate evidence to guide the management of children with esophageal varices may lead to variation in care and the provision of poor-quality care to some children. The aims of the study were to describe approaches taken by pediatric gastroenterologists for the management of esophageal varices in children, and to determine the attitudes of children, parents, and physicians toward screening endoscopy for identification of varices.

METHODS

Canadian pediatric gastroenterologists and hepatologists were questioned about their approaches to screening for esophageal varices and therapy to prevent or treat variceal hemorrhage. Consecutive children with portal hypertension and their parents were surveyed about attitudes to screening endoscopy.

RESULTS

Forty-seven of 72 (65%) physicians responded. Seventy percent of respondents screen for esophageal varices in selected children, most using endoscopy (77%). Fifty-eight percent of respondents who screen for varices would provide primary prophylactic treatment. Most would treat an acute variceal bleed with antibiotics, acid suppression, octreotide, and endoscopy within 24 hours (76%) and then secondary prophylaxis with endoscopic variceal ligation (96%) or β-blockers (28%). Among 29 families surveyed, 63% of parents and 50% of patients would agree to screening endoscopy to understand their risk of variceal bleeding and 67% if prophylactic therapy were available. Families were more concerned about the risk of endoscopic adverse events than were gastroenterologists.

CONCLUSIONS

Pediatric gastroenterologists vary in the care they provide for children at risk for esophageal varices and their attitudes toward the role of screening endoscopy differ from that of their patients. Further evidence is required to support practice guidelines that may reduce variation in care and thus improve its quality.

Correlation of splenic volume with hematological parameters, splenic vein diameter, portal pressure and grade of varices in extrahepatic portal vein obstruction in children

PURPOSE

To study the correlation between the volume of the spleen and hematological parameters, splenic vein diameter, portal pressure before shunt, portal pressure after shunt, reduction of portal pressure and grade of esophageal varices in patients with extrahepatic portal vein obstruction (EHPVO).

METHODS

Twenty-four patients with EHPVO who underwent splenectomy with leino-renal shunt during a period of 2 years were prospectively analyzed. Splenic volumes were measured from CT scans using appropriate volumetry software. In order to standardize the difference in the size of the patients, the splenic volume was expressed as a ratio, the splenic volume index, between the actual volume as measured on the CT scan and the surface area of the body. The splenic vein diameter was measured on the CT portogram and confirmed during surgery using a caliper. The grade of esophageal varices was determined during esophageal endoscopy using the Japanese Research Society for Portal Hypertension classification. The portal pressure was measured by cannulating a venous tributary of the gastro-epiploic arcade and using a pressure transducer.

RESULTS

The splenic volume, expressed as splenic volume index, ranged from 362.15 to 1,849.51 ml/m² (mean 929.23 ± 409.02). Larger splenic volumes were associated with lower hemoglobin and platelet counts and significantly lower total leukocyte counts (p = 0.0003). The portal pressures reduced remarkably following the splenectomy and leino-renal shunt; mean post-shunt pressure 20 ± 6.63 mmHg from mean pre-shunt pressure of 34.33 ± 6.21 mmHg (mean percentage reduction 43.37 ± 16.02%). There was no statistically significant correlation between splenic volume and any of the hemodynamic parameters except a weak correlation with splenic vein diameter. There was no correlation between the splenic vein diameter and the pre-shunt portal pressure; however, there was a statistically significant correlation between the splenic vein diameter and the percentage of post-shunt portal pressure reduction (p = 0.0494).

CONCLUSION

Splenic volume has a weak correlation with splenic vein diameter, but does not correlate with portal pressure or the grade of varix. Splenic vein diameter has a statistically significant correlation with the percentage of portal pressure reduction following a leino-renal shunt. There is a statistically significant negative correlation between the splenic volume and the total leukocyte count.

Portal vein thrombosis, revisited

This review article aims to discuss the aetiology, pathophysiology, clinical presentation, diagnostic workup and management of portal vein thrombosis, either as a primary vascular liver disease in adults and children, or as a complication of liver cirrhosis. In addition, indications and limits of anticoagulant therapy are discussed in detail.

Derivation of a clinical prediction rule for the noninvasive diagnosis of varices in children

BACKGROUND AND OBJECTIVES

Identification of children who are at high risk for having varices using noninvasive tests would enable the selection of children for future studies of primary prophylaxis of variceal hemorrhage, but this has been inadequately studied. The objective of the study was to derive a noninvasive clinical prediction rule that is able to identify children with esophageal varices.

METHODS

Fifty-one consecutive children with liver disease or portal hypertension who underwent endoscopy were included in the present retrospective study. At endoscopy, variceal size was graded on a 4-point Likert scale. Results of physical examination, blood tests, and abdominal ultrasound scan (USS) were recorded. Spleen length on USS was expressed as a standard deviation score (z score). A descriptive univariate analysis was performed on variables that were potentially associated with esophageal varices and multivariate logistic regression was then modeled to derive a clinical prediction rule.

RESULTS

Esophageal varices were found in 17 of the 51 children (33%). Variables found to differ significantly between children with and without varices included platelet/spleen-length z score ratio (P < 0.001), platelet count (P < 0.001), international normalized ratio (P = 0.001), aspartate aminotransferase/alanine aminotransferase ratio (P = 0.002), and albumin (P = 0.003). Using multivariate logistic regression, a model with platelet count, spleen length z score, and albumin as the independent variables had the best fit. Area under the receiver operating characteristic curve for this clinical prediction rule was 0.93 (95% confidence interval 0.85-0.99), sensitivity 94%, specificity 81%, positive predictive value 0.83, negative predictive value 0.94, positive likelihood ratio 5, and negative likelihood ratio 0.06.

CONCLUSIONS

This clinical prediction rule is a simple noninvasive measure that may identify children at high risk for esophageal varices. A prospective validation study is in progress.

Natural history of bleeding after esophageal variceal eradication in patients with extrahepatic portal venous obstruction; a 20-year follow-up

BACKGROUND

Long-term follow-up studies of patients with extrahepatic portal venous obstruction (EHPVO) after eradication of esophageal varices using endoscopic sclerotherapy (EST) are limited.

METHODS

Between 1985 and 1994, 223 patients with bleeding esophageal varices due to EHPVO underwent variceal eradication using EST. Regular annual clinical and endoscopic follow-up data were available for 198 of these patients for a mean period of 19.8 (range: 14-23) years. These data were analyzed retrospectively.

RESULTS

Of the 198 patients, 34 (17.2%) had rebleeding after variceal eradication. The mean duration from variceal eradication to recurrence of bleeding was 5.4 years. The causes of rebleeding were: recurrent esophageal varices in 21 patients, fundal varices in eight, portal gastropathy in three, and ectopic varices in two patients. Esophageal varices reappeared in 39 (19.7%) patients. Fundal varices appeared in 19 (9.5%) patients during follow-up.

CONCLUSIONS

EST is an effective treatment modality for bleeding esophageal varices due to EHPVO. During a follow-up of nearly 20 years after variceal eradication, only about one-sixth of the patients had recurrence of gastrointestinal bleeding. Bleeding was unusual after 10 years had passed since initial variceal eradication.

A case of extrahepatic portal hypertension

Bleeding from the proximal part of the gastrointestinal (GI) tract is not uncommon in children. Children could present with anemia secondary to chronic occult bleeding in the gastrointestinal tract or as anemia secondary to acute exsanguinations and can present in hypovolemic shock. There are various causes of upper GI bleeding in children. A systematic approach in evaluating these children is essential so that the diagnosis is made in timely manner and appropriate management is begun early.

Neonatal Candida albicans septic thrombosis of the portal vein followed by cavernous transformation of the vessel

We report two premature neonates with Candida albicans septic thrombosis of the portal vein who developed, in very early childhood, the sonographic appearance of cavernous transformation of the vessel and/or clinical signs of extrahepatic portal hypertension.

Role of surgical portosystemic shunts in the era of interventional radiology and liver transplantation

Background

In the present era of liver transplantation and transjugular intrahepatic portosystemic shunts, the role and choice of shunt surgery for portal hypertension was reviewed.

Methods

This retrospective study analysed the management of patients with portal hypertension in a tertiary liver transplant unit between June 1993 and May 2002. During this 9-year interval, 394 patients underwent endoscopic control of varices, 235 transjugular intrahepatic portosystemic shunts were inserted, 1142 liver transplants were performed, while only 29 patients needed a surgical portosystemic shunt.

Results

Twenty-nine shunt operations were performed in nine patients with cirrhosis, one patient with congenital hepatic fibrosis and 19 without parenchymal liver disease. There were 12 side-to-side lienorenal, nine mesocaval, three proximal lienorenal, two distal lienorenal, two portacaval and one mesoportal shunts. Encephalopathy was seen in five of 11 patients with a non-selective shunt, but did not occur after side-to-side or selective lienorenal shunt procedures. At a median follow-up of 42·5 months, one mesocaval shunt had thrombosed and one portacaval shunt had stenosed; both were successfully managed by percutaneous intervention. To date, six patients have died; two succumbed to postoperative complications, one of which was related to the shunt.

Conclusion

Patients with Budd–Chiari syndrome and cirrhosis can nearly always be managed by a combination of endoscopy, interventional radiology and liver transplantation. In the rare instances when these therapies fail in patients with cirrhosis, a side-to-side lienorenal shunt is a good option.

[Portal cavenorma: diagnosis, aetiologies and consequences]

Portal cavernoma is a network of veins whose caliber, initially millimetric or microscopic, is increased and which contain hepatopedal portal blood. It results from occlusion, thrombotic and always chronic, of the extra-hepatic portal system. Diagnosis is mainly done by imaging. Clinical signs of portal cavernoma are usually related to extra-hepatic portal hypertension (hematemesis due to rupture of oeso-gastric varices, splenomegaly, rectal bleeding from ano-rectal varices, growth retardation in children) and sometimes to the cause of portal hypertension (abdominal pain, venous bowel infarction). Occurrence of portal thrombosis is often the conjunction of a local cause and a prothrombotic disorder which must be systematically detected. Biliary consequences of cavernoma are related to compression of common bile duct and are usually asymptomatic. In case of jaundice or cholangitis, portal decompression by portosystemic shunt can be performed to treat both biliary symptoms and portal hypertension.

Gastrointestinal bleeding in infancy and childhood

Gastrointestinal (GI) bleeding is an alarming problem in children. Although many causes of GI bleeding are common to children and adults, the frequency of specific causes differs greatly, and some lesions, such as necrotizing enterocolitis or allergic colitis, are unique to children. This article reviews the spectrum of GI bleeding in infants and children. The causes, diagnostic evaluation, and management are discussed, and differences with adult medicine are highlighted.

Portal hypertension in north Indian children

Etiological factors associated with portal hypertension in children influence the decision about therapy and the prognosis. This cross-sectional observational study was performed at a tertiary care centre in northern India from January, 1990 to December, 1994. Children below the age of 14 years with suspected portal hypertension were prospectively assembled into a cohort to determine the etiology and clinical profile of portal hypertension. Of the 115 patients with portal hypertension, 76.5% had extrahepatic portal hypertension (EHPH). Remaining 23.5% of the cases had intrahepatic and post-hepatic causes of portal hypertension. Children with EHPH had a significantly earlier onset of symptoms as compared to those with intrahepatic portal hypertension (p = 0.002) and bled significantly more frequently (p = 0.00). Forty per cent of patients with chronic liver disease (CLD) never had jaundice. History suggestive of potential etiological factors could be elicited in only 7% of EHPH patients. The commonest site of block in splenoportal axis was at the formation of the portal vein. An inverse relation of bleeding rates with duration of illness was seen in EHPH. Of the 10 CLD patients in whom liver biopsy could be done, cirrhosis was present in 6 patients. Understanding the natural history of EHPH and portal hypertension due to other etiologies may have significant implications in choosing the appropriate intervention and predicting the outcome.

Portal hypertension in children

This chapter reviews the common causes of portal hypertension in children. It specifies how the treatment strategy for portal hypertension in patients without significant hepatic dysfunction differs from the management of children with cirrhosis. It describes the application of newer treatment modalities such as TIPS and partial splenic embolization in children and reviews the current recommendations for surgical intervention in these patients.

Endoscopic sclerotherapy for esophageal varices in children with extrahepatic portal venous obstruction: a follow-up study

BACKGROUND

Results of treatment with endoscopic sclerotherapy for esophageal varices in children extrahepatic portal venous obstruction are limited.

METHODS

A prospective study was undertaken of fifty children (mean age, 7.4 +/- 3.8 years; range, 4 months to 14 years) with esophageal variceal bleeding caused by extrahepatic portal venous obstruction (EHPVO) treated by repeated intravariceal endoscopic sclerotherapy (EST) at intervals of 2-3 weeks until eradication (no varices on endoscopy).

RESULTS

Eradication of varices was achieved in 44 children (88%) with a mean of eight sessions per child. In six other cases, variceal grade decreased by 50% from the initial grades. Bleeding episodes at presentation were controlled in all of the children with first ET >. Over a mean follow-up period of 19 months (range, 12-36 months), a total of 15 episodes of rebleeding occurred in 13 children (26%) before the third session of EST and all were controlled with EST. Risk of rebleeding in children with eradicated varices (n = 44) significantly decreased from 0.2 episodes per month to nil after eradication. None of the children without eradicated varices had rebleeding. Thus, EST was successful in controlling rebleeding in all of the cases. Recurrence of varices was observed in five children (10%). None of our children either required surgery for EST failure or died.

CONCLUSIONS

EST is a safe and effective nonsurgical mode of therapy in controlling esophageal variceal bleeding in children with EHPVO. Significant variceal bleeding did not occur during the relatively short follow-up in this series.

Proximal splenorenal shunts for extrahepatic portal venous obstruction in children

OBJECTIVE

The results of proximal splenorenal shunts done in children with extrahepatic portal venous obstruction were evaluated.

SUMMARY BACKGROUND DATA

Extrahepatic portal venous obstruction, a common cause of portal hypertension in children in India, is being treated increasingly by endoscopic sclerotherapy instead of by proximal splenorenal shunt. It is believed that surgery (or the operation) carries high mortality and rebleeding rates and is followed by portosystemic encephalopathy and postsplenectomy sepsis. However, a proximal splenorenal shunt is a definitive procedure that may be more suitable for children, particularly those who have limited access to medical facilities and safe blood transfusion.

METHODS

Between 1976 and 1992, the authors performed 160 splenorenal shunts in children. Twenty were emergency procedures for uncontrollable bleeding and 140 were elective procedures--102 for recurrent bleeding and 38 for hypersplenism.

RESULTS

The overall operative mortality rate was 1.9%--10% (3/160-2/20) after emergency operations and 0.7% (1/140) after elective operations. Rebleeding occurred in 17 patients (11%), and pneumococcal meningitis developed in 1 patient who recovered later. Encephalopathy did not develop in any patient. Four patients died in the follow-up period--two of rebleeding, one of chronic renal failure and a subphrenic abscess, and one of unknown causes. The 15-year survival rate by life table analysis was 95%.

CONCLUSIONS

A proximal splenorenal shunt, a one-time procedure with a low mortality rate and good long-term results, is an effective treatment for children in India with extrahepatic portal venous obstruction.

Side-to-side lienorenal shunt without splenectomy in noncirrhotic portal hypertension in children

Noncirrhotic portal hypertension is a common cause of upper gastrointestinal bleeding in infants, children, and adolescents in India. More than one major bleeding episode, severe hypersplenism, presence of fundal varices, rare blood group, remoteness from the hospital, and patient noncompliance to sclerotherapy formed the main indications for shunt surgery. One hundred four cases of noncirrhotic portal hypertension (age range, 18 months to 20 years) underwent side-to-side lienorenal shunt (SSLR) without splenectomy in a period of 15 years. Splenic veins varying in diameter from 4 to 18 mm and in length from 3 to 4 cm were skeletonized through the root of transverse mesocolon and a shunt of at least 1.5 cm in diameter was constructed. At a mean follow-up of 54 months, 87% of shunts were patent, 13% of shunts were blocked, and 2% were inadequate. Ten percent of the children had rebled, all of whom had a blocked shunt. Growth and development was normal and no patients developed encephalopathy. There was a good correlation between shunt patency on splenoportography and endoscopic disappearance of varices, reduction in the size of spleen and splenic pulp pressure, and improvement of hypersplenism.

Sclerotherapy in extrahepatic portal venous obstruction

One hundred and twenty two patients who presented with variceal bleeding as a result of extrahepatic portal vein obstruction (EHPO) were entered into the sclerotherapy programme with a mean follow up of 23.69 months (range four to 60 months). Eighteen (14.7%) patients were lost to follow up, three (2.4%) patients underwent surgery, and six (4.9%) patients died. Variceal obliteration was achieved in the remaining 95 patients requiring 5.4 (2.4) sessions of sclerotherapy (range 2-18). Seventeen episodes of upper gastrointestinal bleed occurred in 15 patients during sclerotherapy. Recurrence of oesophageal varices was seen in 15 patients. Ten patients developed bulbous gastric varices after obliteration. Major complications including perforation and strictures were seen more commonly in children. Sclerotherapy was associated with a significant reduction in the bleeding rate (bleeds/month/patient) as compared with the presclerotherapy period (p less than 0.001). Endoscopic sclerotherapy is an effective and safe modality in the prevention of variceal bleeds in patients with extrahepatic portal vein obstruction.

Endoscopic sclerotherapy for portal hypertension due to extrahepatic obstruction: long-term follow-up

Between 1982 and 1987, 43 patients with variceal bleeding due to extrahepatic portal obstruction were treated by repeated endoscopic injection sclerotherapy using 1% polidocanol intravariceally. This decreased rebleeding, as evidenced by a decrease in bleeding risk factor (BRF), mean transfusion requirement, and mean number of transfusions per patient per month of follow-up. Differences between pre- and postsclerotherapy parameters were significant (p less than 0.001). The varices were eradicated in 86% of patients. The mean sclerotherapy sessions required were 7.68 +/- 2.39 (SD). Complications were infrequent. Forty-three patients were followed from 5 to 68 months: cumulative survival was 97.7% and varices recurred in 16%. Sclerotherapy avoided a second operation in 21 postsurgical patients. Sclerotherapy for managing variceal bleeding due to extrahepatic portal obstruction is a reasonable alternative to surgery.

Endoscopic sclerotherapy in children

Thirty-eight children, aged 1-15 years, with portal hypertension and recent variceal bleeding, were treated with repeated endoscopic sclerotherapy. Thirty-six of them had extrahepatic portal venous obstruction. Obliteration of varices was achieved in 35 (92%) patients requiring an average of 5.3 sessions per patient. Major complications occurred in seven patients, three of whom had oesophageal perforations and four had oesophageal stricture. Sclerotherapy significantly reduced the rate of rebleeding after the start of sclerotherapy and more so after variceal obliteration.

Assessment of injection sclerotherapy in the management of 152 children with oesophageal varices

A total of 152 consecutive children with oesophageal varices have been endoscopically reviewed since 1979. In all, 108 of these children presented with variceal bleeding which was managed by injection sclerotherapy. Variceal obliteration was achieved in 33 (92 per cent) children with extrahepatic portal hypertension and 54 (75 per cent) with intrahepatic portal hypertension. Prophylactic injection sclerotherapy was used to obliterate large varices in 11 children with no history of haemorrhage. Bleeding episodes occurred in 38 (39 per cent) children before variceal obliteration was complete. However, the mortality rate from variceal bleeding was only 1 per cent. Complications were oesophageal ulceration (29 per cent) and stricture (16 per cent) which both resolved with conservative management. During a mean follow-up period of 2.9 years after sclerotherapy, recurrent oesophageal or gastric varices developed in 12 (12 per cent) cases, with rebleeding in 9 (9 per cent), but all responded successfully to a second course of treatment. These results are superior to contemporary surgical management and injection sclerotherapy should therefore currently be the primary treatment of choice for bleeding oesophageal varices in children.

Endoscopic sclerotherapy for bleeding esophageal varices secondary to extrahepatic portal vein obstruction

Portal hypertension and variceal bleeding secondary to extrahepatic portal vein obstruction continue to present a therapeutic challenge. We performed endoscopic injection sclerotherapy in eight patients with extrahepatic portal vein obstruction and bleeding esophageal varices. In contrast to other reported series, all but one of our patients were adults at the time sclerotherapy was initiated. Six had episodes of continued bleeding after a variety of surgical procedures. After sclerotherapy, five had no further bleeding with a mean follow-up of 26 months. Three patients had episodes of bleeding prior to variceal obliteration; two of these patients underwent surgical intervention after emergency sclerosis to stabilize their condition. Transfusion requirements were less after sclerosis (p = 0.035), although the follow-up has been relatively short (mean, 24 months) compared to the duration of bleeding. Our results suggest that endoscopic sclerotherapy is an effective therapeutic alternative, and perhaps the initial treatment of choice, in patients with extrahepatic portal vein obstruction and bleeding esophageal varices.

Gastrointestinal bleeding in children

This article provides an update on the advances in technologic investigations of upper gastrointestinal bleeding. Lesions responsible for bleeding are discussed from proximal to distal.

Recent advances in diagnosis and treatment of gastrointestinal hemorrhage in infants and children

Gastrointestinal bleeding is a common and occasionally life-threatening problem in infants and children. A careful history and physical examination as well as the application of new endoscopic and radiographic techniques will reveal the source of hemorrhage in most patients. The utility of recently introduced pharmacologic agents and endoscopic techniques in the treatment of peptic disease and variceal hemorrhage in children remains to be determined. A cooperative effort among pediatricians, radiologists, and surgeons should minimize the morbidity and mortality from gastrointestinal tract bleeding in this population.