Esophageal sclerotherapy: an effective modality in children

Esophageal variceal bleeding secondary to portal hypertension: endoscopic sclerotherapy as the first-step treatment

BACKGROUND

Variceal bleeding from the esophagus is an important cause of mortality and morbidity in children with portal hypertension (PHT).

PATIENTS AND METHODS

A series of 69 PHT cases (41 intrahepatic, 28 extrahepatic) have been evaluated in our department since 1990. According to the Child-Pugh classification, 49 cases were in class A, 16 cases were in class B, and 4 cases were in class C at admission. In our protocol, endoscopic sclerotherapy is performed in all patients, and the diagnosis is achieved directly by diagnostic laparoscopy and fine-needle liver biopsy. The procedure is applied under general anesthesia, and 1% aethoxysclerol (polidocanol) is injected paravariceally and intravariceally with the use of a flexible endoscope.

RESULTS

The Sugiura procedure was performed in nine patients who presented with recurrent bleeding episodes despite the strict sclerotherapy protocol. Liver transplantation was performed in two patients who were in Child class C. The total mortality rate in this series was 7% (5/69).

CONCLUSION

Endoscopic sclerotherapy, as presented herein, decreases the need for additional surgical interventions in children with PHT.

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 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.

Selective distal splenorenal shunts for intractable variceal bleeding in pediatric portal hypertension

The treatment of portal hypertension in the pediatric population has undergone an evolution toward less invasive methods of care. With the advent of endoscopic sclerotherapy, surgery is less common in the acute care of these patients. Few reports deal with the role of portosystemic shunting in the emergent management of variceal hemorrhage in children. To address this issue, the authors studied the medical records of all pediatric patients at their institution who underwent placement of a shunt for portal hypertension during the last 10 years. Nine patients underwent a total of 10 emergent or semiurgent shunting procedures. Seven were boys and two were girls. Six patients had portal hypertension as a result of intrahepatic disease. Two had extrahepatic portal vein thrombosis. Five children had abnormal hepatic function. The median age at the time of the procedure was 9 years. The indication for surgical shunting in all cases was gastrointestinal hemorrhage not responsive to sclerotherapy. Eight patients underwent emergent distal splenorenal shunts (DSRS), and two underwent a nonselective mesocaval shunt, with one undergoing both. Postoperatively all patients had cessation of bleeding. Operative mortality was zero. Early complications included ascites (3), small bowel obstruction (1), and hepatorenal syndrome (1). The child who underwent a nonselective shunt procedure had encephalopathy. Two DSRS thrombosed, requiring reexploration; eight shunts remained patent. Three patients eventually had orthotopic liver transplantation (OLT) because of progressive hepatic failure. Two children died; neither death was shunt related.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Treatment of portal hypertension in children

The management of children with portal hypertension (PH) has substantially changed owing to the good results and broader application of both endoscopic sclerotherapy and orthotopic liver transplantation (OLT). Since the introduction of sclerotherapy for the treatment of bleeding esophageal varices, the number of surgical procedures has sharply decreased. Until the early 1980s, however, the treatment of choice of bleeding esophageal varices was based on different variations of two main types of open surgery: devacularization and transection operations and portosystemic shunts. The experience with nonshunt procedures is limited in the pediatric population. Literature reports from the last 25 years have emphasized a number of restrictions related to portosystemic shunts in small subjects. However, portosystemic shunts, selective or not, can be performed even in very young subjects with high rates of success. From 1974 to 1984 the distal splenorenal shunt (DSRS) was the procedure of choice for the treatment of children with variceal bleeding in our institution. Forty-two children underwent DSRS during this period. Since 1985, when endoscopic variceal sclerotherapy (EVS) replaced DSRS as the first therapeutic option in our service, this shunt has been performed in only 8 children in whom EVS has failed, none of them during the last 2 years. In this cohort of 50 cases of DSRS, the shunt patency has increased from 71% in the first 7 patients to 95% thereafter. There has been no perioperative mortality. From 1985 to April 1993, 107 children were submitted to EVS sessions for the treatment of esophageal varices bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)

Portal vein thrombosis: a review

Portal vein thrombosis (PVT) is a rare condition that affects both children and adults. This article reviews the existing literature on PVT, with an emphasis on recent developments. A comprehensive description of etiologic factors and clinical aspects is presented. Treatment issues that remain unresolved are addressed and a framework for the diagnostic work-up and management of patients with PVT is provided.

Big shunts for small patients with portal hypertension: a bit of history

This is a brief resume of my personal experiences that led to the development of two portosystemic shunt procedures designed to be used in small patients with bleeding varices and portal hypertension. Both enable one to decompress the congested protal venous system in the preschool-aged group when about two thirds of such patients begin to suffer their first life threatening bleeding episodes.

Management of variceal bleeding in patients with extrahepatic portal vein thrombosis

Patients with extrahepatic portal vein thrombosis may present from infancy through adulthood with variceal bleeding. Physiologically, such patients differ from patients with cirrhosis and variceal bleeding in that they have a normal liver and maintain good portal perfusion through hepatopedal collaterals. Complete evaluation of these patients requires identification of the bleeding site by endoscopy, definition of the anatomy by angiography, and confirmation of a normal liver by biopsy examination. Causative factors, including hypercoagulable states, should be evaluated. Therapeutic options range from noninterventive, through ablative procedures, to shunt operations. The goal should be definitive control of bleeding and return to a normal lifestyle. Distal splenorenal shunt offers the best option if technically feasible, but if no shuntable veins are patent, ablative procedures and sclerotherapy may be required. A noninterventive, noninvestigational approach is inappropriate in patients who can be offered definitive therapy. Splenectomy for hypersplenism should not be done in these patients.

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.

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.

Management of variceal bleeding in patients with noncirrhotic portal vein thrombosis

Since 1971, 70 patients have been seen at Emory University Hospital with gastroesophageal varices secondary to extrahepatic portal vein thrombosis (PVT). Thirty-seven of these patients had had prior major operative therapy. In only three patients (8%) was shunt surgery successful, and there was a high incidence of rebleeding, other morbidity, and mortality. Of especial note are the serious consequences of simple splenectomy; splenomegaly and thrombycytopenia should rarely, if ever, be used as indication for splenectomy in portal hypertension. In 1977, the use of selective distal splenorenal shunt (DSRS) was begun at Emory in this population and a selective shunt has been possible in 24 of 29 patients (83%) who had had no prior operative therapy. Results have been excellent with a greater than 90% patency rate, long-term portal perfusion in all, no encephalopathy, and late rebleeding in one patient. Quantitative studies at 3-6 years show stability of liver function, significant decrease in spleen size, and rise in platelet count. However, long-term follow-up (greater than 15 years) is required in PVT patients before definitive assessment can be obtained. A specific problem of the PVT patient is late shunt stenosis which requires close observation; dilatation of the shunt was performed in six of the 24 patients with a patent shunt. Poor results with non-shunt operative procedures in PVT were again documented. The proper role of endoscopic variceal sclerotherapy is not yet clear, but appears to be an excellent addition to the therapeutic options. In conclusion, for patients with a patent splenic vein, initial therapy should be a selective shunt; for patients without a patent splenic venous system, endoscopic sclerotherapy is the procedure of choice.

Manometric and pH consequences of esophageal endosclerosis in children

Twenty-seven manometric and 22 18-hour pH monitoring studies were done in 17 consecutive patients undergoing esophageal endosclerosis. Prior to endosclerosis, esophageal manometry was normal in eight of nine patients. Peristaltic dysfunction was observed in all 13 postendosclerosis patients and consisted of (1) decreased mean peristaltic amplitude pressures. Pressures were 61.4 and 74.7 mmHg at 0 to 2 cm and 3 to 4 cm above the lower esophageal sphincter (LES), respectively, prior to treatment. After endosclerosis, values fell to 30.2 and 43.3 mmHg; (2) a drop in mean resting LES pressure from 22.3 mmHg before endosclerosis to 17.1 mmHg afterward and (3) an increase in the rate of peristaltic propagation failure from 12% to 26% after endosclerosis. Esophageal pH monitoring demonstrated gastroesophageal reflux (GER) in three of seven patients before endosclerosis and in five of 11 patients afterward. Because of the major incidence of GER before endosclerosis, the procedure could not be causally incriminated. However, GER was roughly correlated with the severity of the manometric dysfunction. There was no correlation of GER or manometric abnormality with the number of endosclerosis treatment nor the interval between endosclerosis and pH and manometric studies. The remote sequelae of the abnormalities are conjectural.

Extrahepatic portal hypertension in children. Long-term evaluation

A long-term evaluation of 43 children with extrahepatic portal hypertension indicates a high success rate and excellent subsequent health when a splenorenal or mesocaval shunt can be performed. On the other hand, makeshift shunts inevitably fail. Direct operations are considerably less successful than standard shunts. Esophagogastric resections with interpositions result in long-term freedom from bleeding in only about half the cases, and portoazygous disconnection procedures have been uniformly disappointing. Sclerotherapy in a relatively recent experience has been quite successful, but long-term results are presently unavailable. The condition carries a significant mortality rate. Complications from failed operations, division of the vena cava, and multiple transfusions are numerous. The general health of long-term survivors is excellent in those with successful operations, and is surprisingly good for patients whose operations have been unsuccessful and for those who have had no operations.