Esophageal varices: current management in children

[Cavernous transformation of the portal vein in children: about 11 cases]

Le cavernome portal est la conséquence d'une occlusion chronique, du système porte extra-hépatique formé d'un réseau de veines dont le calibre est augmenté et au sein desquelles chemine un sang portal hépatopéte. Chez l'enfant, est une cause majeure d'hypertension portale dite «pré ou infra-hépatique» ou encore «extra-hépatique». Onze cas de cavernome porte parmi 78 cas d'hypertension portale ont été colligés au service sur une période allant du Janvier 2003 au Septembre 2012. L’âge de nos patients variait entre 2 et 15 ans et le sexe ratio est de 1,75. Tous nos patients étaient admis au stade d'hypertension portale avec la splénomégalie SMG (100% des cas); hémorragies digestives (63%); ascite (36%); la circulation veineuse collatérale CVC et l'hépatomégalie HMG (27%). L'exploration endoscopique a objectivé la présence de varices ‘sophagiennes dans tous les cas avec une gastropathie hypertensive dans 27% et des varices ectopiques chez 36%. Les perturbations biologiques étaient dominées par la pancytopénie. Le bilan de thrombophilie était demandé pour tous les malades mais réalisé mais n'est réalisé que chez trois revenus normaux chez deux et a objectivé une baisse de protéine S chez le troisième. L’échographie abdominale était le moyen de diagnostic positif et l’écho-doppler a confirmé l'HTP chez tous nos patients. Aucun de nos malades n'a pu être opéré pour le moment. La ligature a été réalisée chez 54,5%. Dix patients ont nécessité une transfusion sanguine. L’évolution globale de nos patients est favorable. La durée moyenne d’évolution du cavernome porte chez nos patients est de quatre ans.

Extrahepatic portal hypertension in children: observations on three surgical procedures

This paper presents a comparative prospective study of three modalities of surgical treatment for extrahepatic portal hypertension in children: central splenorenal shunt after splenectomy (CSS), side-to-side lienorenal shunt (SSLR) without splenectomy, and splenectomy and gastroesophageal devascularization (SGD). In an 18-month period, 27 procedures were performed: 10 CSS, 10 SSLR, and seven SGD. The outcomes were evaluated by fall in portal pressures, hematological parameters, shunt patency, splenic regression, and disappearance of esophageal varices. All three procedures were comparable in the fall of portal pressure after surgery. The average blood loss and operating time were statistically significant in favor of SSLR compared with CSS. At 3-month follow-up, shunt patency was confirmed by duplex Doppler study in all the patients in the SSLR group and in nine out of 10 patients in the CSS group. In the CSS and SGD groups, hypersplenism resolved in all the patients. In the SSLR group, blood counts improved in only five out of eight affected children. No patient re-bled during a follow-up of 3-5 years. There were no cases of hepatic encephalopathy or overwhelming postsplenectomy sepsis. In conclusion, CSS is useful when there is a large spleen, severe hypersplenism, and a shuntable splenic vein. SSLR is suitable when there is only mild splenomegaly, mild hypersplenism, and a shuntable splenic vein. Splenectomy and devascularization is the choice when there is no shuntable splenic vein.

Octreotide therapy for control of acute gastrointestinal bleeding in children

OBJECTIVES

To evaluate the outcomes of octreotide use in children with gastrointestinal bleeding with or without portal hypertension.

METHODS

The medical charts of children who received continuous octreotide infusion for the indication of gastrointestinal bleeding from January 1995 to December 2000 were retrospectively reviewed.

RESULTS

Twenty-one children with portal hypertension received octreotide infusions (1-2 microg/kg/h) during 35 gastrointestinal bleeding episodes. The duration of infusion ranged from 19 hours to 7 days. Bleeding ceased in 71% of children. Post-treatment rebleeding occurred in 52%, and the mortality was 19%. Response to octreotide, rebleeding, and mortality did not differ significantly between patients with or without intrinsic liver disease. Twelve children with gastrointestinal bleeding unrelated to portal hypertension received octreotide during 14 episodes. The duration of octreotide ranged from 3 hours to 36 days. Fifty percent of children had resolution of bleeding during the infusion. Post-treatment rebleeding occurred in 29%, and the mortality was 50%. No major adverse events were observed in either group.

CONCLUSIONS

A high rate of bleeding control was achieved with octreotide during acute gastrointestinal bleeding in children with portal hypertension. However, controlled studies are needed for more definitive description of its clinical effects. The role of octreotide is less clear in gastrointestinal bleeding unrelated to portal hypertension.

Biliary atresia: an update on our understanding of the disorder

Biliary atresia is the leading cause of cholestasis in infants younger than 3 months. It is also the leading indication for liver transplantation in children. This review focuses on recent advances in the etiology, diagnosis, and management of biliary atresia.

Causes and management of portal hypertension in the pediatric population

Therapeutic options for children with portal hypertension now include a broad range of pharmacologic, endoscopic, and surgical procedures. Thoughtful application of all of these options can improve quality of life by decreasing the complications of portal hypertension and can decrease mortality by preventing the consequences of variceal hemorrhage. The development of portal hypertensive gastropathy following palliative procedures such as endoscopic sclerotherapy and band ligation may limit their long-term success in children. The excellent results now obtained with selective portosystemic shunts and liver transplantation assure that definitive surgical treatments will continue to be important components in the treatment of children with portal hypertensive complications or progressive liver disease. Evolving procedures, such as TIPS, represent excellent short-term life-preserving techniques to stabilize critically ill patients while awaiting liver transplantation. Their role in the future, long-term management of children is yet to be defined.