A prospective study of endoscopic esophageal variceal ligation using a multiband ligator

Emergencies in paediatric hepatology

The aetiology of several liver diseases in children is age specific and many of these conditions have significant and potentially long-term clinical repercussions if not diagnosed early and managed in a timely fashion. We address 5 clinical scenarios that cover most of the diagnostic and therapeutic emergencies in children: infants with liver disease; acute liver failure; management of bleeding varices; liver-based metabolic disorders; and liver tumours and trauma. A wide spectrum of conditions that cause liver disease in infants may present as conjugated jaundice, which could be the only symptom of time-sensitive disorders - such as biliary atresia, metabolic disorders, infections, and haematological/alloimmune disorders - wherein algorithmic multistage testing is required for accurate diagnosis. In infantile cholestasis, algorithmic multistage tests are necessary for an accurate early diagnosis, while vitamin K, specific milk formulae and disease-specific medications are essential to avoid mortality and long-term morbidity. Management of paediatric acute liver failure requires co-ordination with a liver transplant centre, safe transport and detailed age-specific aetiological work-up - clinical stabilisation with appropriate supportive care is central to survival if transplantation is indicated. Gastrointestinal bleeding may present as the initial manifestation or during follow-up in patients with portal vein thrombosis or chronic liver disease and can be managed pharmacologically, or with endoscopic/radiological interventions. Liver-based inborn errors of metabolism may present as encephalopathy that needs to be recognised and treated early to avoid further neurological sequelae and death. Liver tumours and liver trauma are both rare occurrences in children and are best managed by a multidisciplinary team in a specialist centre.

Factors associated with bleeding after endoscopic variceal ligation in children

BACKGROUND

Endoscopic variceal ligation (EVL) is a widely accepted treatment for esophagogastric varices in patients with portal hypertension (PHT). It is used for urgent treatment and prophylactic treatment of esophagogastric varices in pediatric as well as adult patients. However, major life-threatening adverse events such as early rebleeding can occur. Although early rebleeding after EVL among children and adolescents has been reported, the risk factors remain obscure. This study evaluated the risk factors for early rebleeding after EVL in children and adolescents.

METHODS

The subjects were children and adolescents (<18 years) with PHT who underwent EVL for esophagogastric varices. Early rebleeding was defined as hematemesis, active bleeding, or blood retention in the stomach, confirmed by esophagogastroduodenoscopy from 2 h to 5 days after EVL.

RESULTS

A total of 50 EVL sessions on 22 patients were eligible for this study. There were four episodes of early rebleeding. No other major adverse event has occurred. Multivariate analysis showed that EVL implemented at cardiac varices just below the esophagogastric junction (EGJ), within 5 mm from the EGJ, is the independent factor for a higher risk of early rebleeding: odds ratio 18.2 (95% confidence interval: 1.40-237.0), P = 0.02.

CONCLUSIONS

Children and adolescents who undergo EVL for cardiac varices just below the EGJ have a higher risk of early rebleeding than those who do not.

Gastrointestinal endoscopy in children and adults: How do they differ?

Gastrointestinal endoscopy has grown dramatically over the past century, and with subsequent improvements in technology and anaesthesia, it has become a safe and useful tool for evaluation of GI pathology in children. There are substantial differences between paediatric and adult endoscopy beyond size, including: age-related patho-physiology and the different spectrum of diseases in children. Literature on endoscopic procedures in children is sparse but significant. The present review aims at describing the current knowledges on paediatric endoscopy practice and highlights the main areas of differences between paediatric and adult practice.

Pediatric Endoscopy, Update 2020

Optimal management of pediatric endoscopy requires a multidisciplinary approach. In most hospitals, endoscopy in pediatric patients is performed by conventional gastroenterologists and only a few centers have specialized pediatric gastroenterologists. This is due to the fact that the number of pediatric gastroenterologists is limited and not all of them are experienced in endoscopic techniques. However, there are also some pediatric centers offering a high-quality and high-volume endoscopy service provided by very experienced pediatric gastroenterologists. Up to now, the literature on pediatric endoscopy is rather sparse. In this article, we describe current knowledge and practice of endoscopic procedures in pediatric patients, which should be relevant for both the adult and pediatric gastroenterologists.

Diagnostic and therapeutic approach to upper gastrointestinal bleeding

BACKGROUND

There is a lack of clarity about the approach to and management of upper gastrointestinal (UGI) bleeding in children.

AIM

To examine the recent literature on UGI bleeding in children in order to outline the diagnostic approach and management.

METHODS

The English language literature was searched for articles on UGI bleeding in children. Special attention was paid to its prevalence, risk factors, clinical approach and management.

RESULTS

Although UGI bleeding is a common complication (10%) in paediatric intensive care units (PICU), clinically significant UGI bleeding (haemodynamic instability, fall in haemoglobin by 2 g/dL and/or a requirement for blood transfusion) is less common (1.6%). In low- and middle-income countries, clinically significant UGI bleeding is commonly owing to variceal bleeding whereas non-variceal aetiologies (e.g. peptic ulcer disease) are common in high-income countries. The fundamental clinical principles of managing UGI bleeding are immediate assessment of severity, detecting possible causes and stabilising the haemodynamic status. In suspected cases of variceal bleeding, intravenous octreotide and, in non-variceal bleeding, administration of a proton pump inhibitor (PPI) should be commenced immediately. UGI endoscopy plays a vital role in diagnosis and management. Over-transfusion should be avoided (target haemoglobin 7-9 g/dL). Stress ulcer prophylaxis is recommended in a select group of patients in PICUs (e.g. respiratory failure, coagulopathy and paediatric risk of mortality score ≥10).

CONCLUSIONS

In clinically significant UGI bleeding, the primary goal is to restore the haemodynamic status, followed by early endoscopy. Intravenous octreotide in suspected variceal and PPI in non-variceal bleeding should be administered early. Stress ulcer prophylaxis should be restricted to high-risk children only.

Evaluation of endoscopic secondary prophylaxis in children and adolescents with esophageal varices

ABSTRACT BACKGROUND Bleeding of esophageal varices is the main cause of morbidity and mortality in children and adults with portal hypertension and there are few studies involving secondary prophylaxis in children and adolescents. OBJECTIVE To evaluate the efficacy of endoscopic secondary prophylaxis in prevention of upper gastrointestinal bleeding in children and adolescents with esophageal varices. METHODS This is a prospective analysis of 85 patients less than 18 years of age with or without cirrhosis, with portal hypertension. Participants underwent endoscopic secondary prophylaxis with sclerotherapy or band ligation. Eradication of varices, incidence of rebleeding, number of endoscopic sessions required for eradication, incidence of developing gastric fundus varices and portal hypertensive gastropathy were evaluated. RESULTS Band ligation was performed in 34 (40%) patients and sclerotherapy in 51 (60%) patients. Esophageal varices were eradicated in 81.2%, after a median of four endoscopic sessions. Varices relapsed in 38 (55.1%) patients. Thirty-six (42.3%) patients experienced rebleeding, and it was more prevalent in the group that received sclerotherapy. Gastric varices and portal hypertensive gastropathy developed in 38.7% and 57.9% of patients, respectively. Patients undergoing band ligation showed lower rebleeding rates (26.5% vs 52.9%) and fewer sessions required for eradication of esophageal varices (3.5 vs 5). CONCLUSION Secondary prophylaxis was effective in eradicating esophageal varices and controlling new upper gastrointestinal bleeding episodes due to the rupture of esophageal varices. Band ligation seems that resulted in lower rebleeding rates and fewer sessions required to eradicate varices than did sclerotherapy.

Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines

This guideline refers to infants, children, and adolescents ages 0 to 18 years. The areas covered include indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography; and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease has been dealt with in other guidelines and are therefore not mentioned in this guideline. Training and ongoing skill maintenance are to be dealt with in an imminent sister publication to this.

Prediction of esophageal varices in biliary atresia: Derivation of the "varices prediction rule", a novel noninvasive predictor

BACKGROUND AND AIMS

Liver fibrosis and cirrhosis are nearly inevitable following Kasai portoenterostomy (KPE) for biliary atresia (BA), though the formation of varices is not. We sought to assess the value of noninvasive indices of portal hypertension (PHT), in predicting significant esophageal varices, and to develop a novel prediction model through regression modeling.

METHODS

This is a retrospective, observational study with analysis of routine biochemical and ultrasound data. Five indices were examined: AST-to-platelet ratio index (APRi); hepatic artery resistance index (HARI); spleen size z score (SSAZ); platelet count-to-SSAZ ratio (P/SSAZ); and clinical prediction rule (CPR) [(0.75 × platelets)/(SSAZ+5)]+(2.5 × albumin), each at specific time points following KPE (6 months, 1 year and 2 years). Significant varices were defined as grade ≥ 2 at endoscopy (screening or following a gastrointestinal bleed). AUROC was calculated for all indices. Univariate analysis was used to assess variables' suitability for inclusion in a subsequent multivariate logistic regression model to generate a predictive index. Data are quoted as median (range). P values ≤ 0.05 were regarded as significant.

RESULTS

195 infants (median age at KPE of 55 days [11-216]) were analyzed. 42 (22%) had significant varices (median time to first presentation of varices of 1.20 [0.20-6.40] years). CPR and APRi (AUROCs ranging from 0.73-0.80 and 0.69-0.83 respectively) performed best overall. Multiple logistic regression modeling yielded a novel predictor at 6 months post-KPE: the Varices Prediction Rule (albumin × platelets/1000) (AUROC 0.75, sensitivity 86%, sensitivity 71%).

CONCLUSIONS

Noninvasive indices such as CPR, APRi and now VPR can provide a tool for stratifying BA patients for elective endoscopy and possible preemptive intervention.

Interobserver Agreement on Endoscopic Classification of Oesophageal Varices in Children

OBJECTIVES

Data regarding agreement on endoscopic features of oesophageal varices in children with portal hypertension (PH) are scant. The aim of this study was to evaluate endoscopic visualisation and classification of oesophageal varices in children by several European clinicians, to build a rational basis for future multicentre trials.

METHODS

Endoscopic pictures of the distal oesophagus of 100 children with a clinical diagnosis of PH were distributed to 10 endoscopists. Observers were requested to classify variceal size according to a 3-degree scale (small, medium, and large, class A), a 2-degree scale (small and large, class B), and to recognise red wales (presence or absence, class Red). Overall agreement was considered fair if Fleiss and Cohen κ test was ≥0.30, good if ≥0.40, excellent if ≥0.60, and perfect if ≥0.80.

RESULTS

Agreement between observers was fair with class A (κ = 0.34) and class B (κ = 0.38), and good with class Red (κ = 0.49). The agreement was good on presence versus absence of varices (class A = 0.53, class B = 0.48). The agreement among the observers was good in class A when endoscopic features of severe PH (medium and large sizes, red marks) were grouped and compared with mild features (absent and small varices) (κ = 0.58).

CONCLUSIONS

Experts working in different centres show a fairly good agreement on endoscopic features of PH in children, although a better training of paediatric endoscopists may improve the agreement in grading severity of varices in this setting.

Surviving Sengstaken

AIM OF THE STUDY

To report the outcomes of children who underwent Sengstaken-Blakemore tube (SBT) insertion for life-threatening haemetemesis.

METHODS

Single institution retrospective review (1997-2012) of children managed with SBT insertion. Patient demographics, diagnosis and outcomes were noted. Data are expressed as median (range).

MAIN RESULTS

19 children [10 male, age 1 (0.4-16) yr] were identified; 18 had gastro-oesophageal varices and 1 aorto-oesophageal fistula. Varices were secondary to: biliary atresia (n=8), portal vein thrombosis (n=5), alpha-1-anti-trypsin deficiency (n=1), cystic fibrosis (n=1), intrahepatic cholestasis (n=1), sclerosing cholangitis (n=1) and nodular hyperplasia with arterio-portal shunt (n=1). Three children deteriorated rapidly and did not survive to have post-SBT endoscopy. The child with an aortooesophageal fistula underwent aortic stent insertion and subsequently oesophageal replacement. Complications included gastric mucosal ulceration (n=3, 16%), pressure necrosis at lips and cheeks (n=6, 31%) and SBT dislodgment (n=1, 6%). Six (31%) children died. The remaining 13 have been followed up for 62 (2-165) months; five required liver transplantation, two underwent a mesocaval shunt procedure and 6 have completed endoscopic variceal obliteration and are under surveillance.

CONCLUSIONS

SBT can be an effective, albeit temporary, life-saving manoeuvre in children with catastrophic haematemesis.

Screening and Prophylaxis for Varices in Children with Liver Disease

Esophageal varices in children with portal hypertension are quite common. Bleeding from these varices frequently occurs. Prophylactic measures to prevent such bleeding can be undertaken either before ("primary," prompted by a screening endoscopy) or after ("secondary") an initial variceal bleed. There are no clear pediatric guidelines for primary or secondary prophylaxis of esophageal varices. Adult studies clearly support the use of pharmacologic (beta blockers) and endoscopic (endoscopic band ligation, EBL) management for both primary and secondary prophylaxis of esophageal varices in patients with portal hypertension. Pediatric studies are limited. There are inadequate data to recommend use of beta blockers to prevent variceal bleeding or rebleeding in children with portal hypertension. There is very limited support for EBL for primary prophylaxis in children and more compelling support for EBL for secondary prophylaxis. Further randomized controlled studies are needed but are difficult to implement in this vulnerable population.

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.

Experiences with endoscopic interventions for variceal bleeding in children with portal hypertension: a single center study

PURPOSE

The aim of this study was to compare the efficacy and safety of band ligation and injection sclerotherapy in the endoscopic treatment of children with variceal bleeding.

METHODS

The study population included 55 children, all of whom were treated at the time of endoscopic diagnosis of esophageal varices at Asan Medical Center, Seoul, Korea, between January 1994 and January 2011. The primary outcomes included initial success rates and duration of hemostasis after endoscopic management (band ligation vs. injectionsclerotherapy).

RESULTS

The mean age was 6.7±5.2 years and the mean follow-up time was 5.4±3.7 years. The most common cause of esophageal varices was biliary atresia. Of 55 children with acute variceal bleeding, 39 had band ligation and 16 had injection sclerotherapy. No differences between groups were observed in terms of the size, location, and presence of red color sign. The success rates of band ligation and sclerotherapy in the control of acute bleeding episodes were 89.7% and 87.5%. The mean duration of hemostasis after endoscopic intervention was 13.2±25.1 months. After one year, 19 of 39 patients (48.7%) treated with band ligation and 7 of 16 patients (43.8%) with injection sclerotherapy had experienced rebleeding episodes. Complications after the procedures were observed in 10.3% and 18.8% of children treated with band ligation and injection sclerotherapy.

CONCLUSION

The results of our current study suggest that band ligation and injection sclerotherapy are equally efficient treatments for the control of acute variceal bleeding and prevention of rebleeding.

Results of a stepwise approach to extrahepatic portal vein obstruction in children

BACKGROUND

The management of extrahepatic portal vein obstruction (EHPVO) in children is controversial. We report our experience with a prospective evaluation of a stepwise protocol based on severity of portal hypertension and feasibility of mesoportal bypass (MPB).

METHODS

After diagnosis, children with EHPVO underwent surveillance endoscopies and received nonselective β-blockers (NSBBs) or endoscopic variceal obliteration (EVO) when large varices were detected. In patients who failed NSBBs and EVO, we considered MPB as first-line and shunts or transjugular intrahepatic portosystemic shunt (TIPS) as second-line options.

RESULTS

Sixty-five children, median age 12.5 (range 1.6-25.8), whose age at diagnosis was 3.5 (0.2-17.5) years, were referred to our unit. Forty-three (66%) had a neonatal illness, 36 (55%) an umbilical vein catheterisation. Thirty-two (49%) presented with bleeding at a median age of 3.8 years (0.5-15.5); during an 8.4-year follow-up period (1-16), 43 (66%) had a bleeding episode, 52 (80%) were started on NSBBs, 55 (85%) required EVO, and 33 (51%) required surgery or TIPS. The Rex recessus was patent in 24 of 54 (44%), negatively affected by a history of umbilical catheterisation (P = 0.01). Thirty-four (53%) patients underwent a major procedure: MPB (13), proximal splenorenal (13), distal splenorenal (2), mesocaval shunt (3), TIPS (2), and OLT (1). At the last follow-up, 2 patients died, 53 of 57 (93%) are alive with bleeding control, 27 of 33 (82%) have a patent conduit.

CONCLUSIONS

Children with EHPVO have a high rate of bleeding episodes early in life. A stepwise approach comprising of medical, endoscopic, and surgical options provided excellent survival and bleeding control in this population.

Recent trends in the endoscopic management of variceal bleeding in children

Variceal bleeding results in significant morbidity and mortality in both children and adults. The guidelines for the management of variceal bleeding are well established in adults but not in children as there have been insufficient pediatric studies of this disorder. In addition, the adult guidelines for treatment of variceal bleeding cannot be applied directly to children as the etiology and natural course of this disease differs between children and adults. Examples of recommended treatments in children include endoscopic variceal ligation as secondary prophylaxis for biliary atresia whereas a meso-Rex shunt operation for extrahepatic portal vein obstruction. In this review, we discuss prophylaxis options and some technical aspects of endoscopic management for variceal bleeding in children.

Endoscopic and pharmacological secondary prophylaxis in children and adolescents with esophageal varices

OBJECTIVE

The aim of this study was to describe the results of endoscopic secondary prophylaxis, alone or in combination with propranolol, used to prevent upper gastrointestinal bleeding (UGIB) in children and adolescents with esophageal varices.

METHODS

This observational study followed 43 patients younger than 18 years who received secondary prophylaxis between August 2001 and December 2009. Sclerotherapy and/or band ligation were performed, and propranolol was used when no contraindications were present. The rebleeding rate, number of endoscopic sessions required for variceal eradication, rate of varix recurrence, the occurrence of varices at the gastric fundus, and the occurrence of portal hypertensive gastropathy were evaluated.

RESULTS

Endoscopic prophylaxis in combination with propranolol was performed in 25 patients (58.1%) and endoscopic prophylaxis alone was performed in 18 patients (41.9%). Esophageal varices were eradicated in all of the patients after a median of 3 sessions. Varices recurred in 22 patients (51.2%). Rebleeding occurred in 13 patients (30.2%). Fundal varices and portal hypertensive gastropathy developed in 31% and 61.9% of patients, respectively. No deaths related to the endoscopic procedure or UGIB occurred. No statistically significant differences in any of the studied variables were observed when comparing endoscopic prophylaxis with propranolol and endoscopic prophylaxis alone.

CONCLUSIONS

No significant differences were observed between sclerotherapy and band ligation. Secondary prophylaxis was effective in eradicating esophageal varices. The use of propranolol did not affect the results of the endoscopic prophylaxis. Furthermore, randomized studies will be necessary to assess the best form of prevention during childhood.

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.

Guidelines for the diagnosis and treatment of extrahepatic portal vein obstruction (EHPVO) in children

INTRODUCTION

Extrahepatic portal vein obstruction is an important cause of portal hypertension among children. The etiology is heterogeneous and there are few evidences related to the optimal treatment.

AIM AND METHODS

To establish guidelines for the diagnosis and treatment of EHPVO in children, a group of gastroenterologists and pediatric surgery experts reviewed and analyzed data reported in the literature and issued evidence-based recommendations.

RESULTS

Pediatric EHPVO is idiopathic in most of the cases. Digestive hemorrhage and/or hypersplenism are the main symptoms. Doppler ultrasound is a non-invasive technique with a high degree of accuracy for the diagnosis. Morbidity is related to variceal bleeding, recurrent thrombosis, portal biliopathy and hypersplenism. Endoscopic therapy is effective in controlling acute variceal hemorrhage and it seems that vasoactive drug therapy can be helpful. For primary prophylaxis of variceal bleeding, there are insufficient data for the use of beta blockers or endoscopic therapy. For secondary prophylaxis, sclerotherapy or variceal band ligation is effective; there is scare evidence to recommend beta-blockers. Surgery shunt is indicated in children with variceal bleeding who fail endoscopic therapy and for symptomatic hypersplenism; spleno-renal or meso-ilio-cava shunting is the alternative when Mesorex bypass is not feasible due to anatomic problems or in centers with no experience.

CONCLUSIONS

Prospective control studies are required for a better knowledge of the natural history of EHPVO, etiology identification including prothrombotic states, efficacy of beta-blockers and comparison with endoscopic therapy on primary and secondary prophylaxis.

Portal vein thrombosis in children and adolescents: 20 years experience of a pediatric hepatology reference center

CONTEXT

Portal vein thrombosis refers to a total or partial obstruction of the blood flow in this vein due to a thrombus formation. It is an important cause of portal hypertension in the pediatric age group with high morbidity rates due to its main complication - the upper gastrointestinal bleeding.

OBJECTIVE

To describe a group of patients with portal vein thrombosis without associated hepatic disease of the Pediatric Hepatology Clinic of the Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil with emphasis on diagnosis, presentation form and clinical complications, and the treatment of portal hypertension.

METHODS

This is a descriptive study of a series of children and adolescents cases assisted from January 1990 to December 2010. The portal vein thrombosis diagnosis was established by ultrasound.

RESULTS

Of the 55 studied patients, 30 (54.5%) were male. In 29 patients (52.7%), none of the risk factors for portal vein thrombosis was observed. The predominant form of presentation was the upper gastrointestinal bleeding (52.7%). In 20 patients (36.4%), the initial manifestation was splenomegaly. During the whole following period of the study, 39 patients (70.9%) showed at least one episode of upper gastrointestinal bleeding. The mean age of patients in the first episode was 4.6 ± 3.4 years old. The endoscopic procedure carried out in the urgency or electively for search of esophageal varices showed its presence in 84.9% of the evaluated patients. The prophylactic endoscopic treatment was performed with endoscopic band ligation of varices in 31.3% of patients. Only one died due to refractory bleeding.

CONCLUSIONS

The portal vein thrombosis is one of the most important causes of upper gastrointestinal bleeding in children. In all non febrile children with splenomegaly and/or hematemesis and without hepatomegaly and with normal hepatic function tests, it should be suspect of portal vein thrombosis. Thus, an appropriate diagnostic and treatment approach is desirable in an attempt to reduce morbidity and mortality.

Etiology and management of hemorrhagic complications of portal hypertension in children

PORTAL HYPERTENSION IN CHILDREN REPRESENTS A PARTICULAR DIAGNOSTIC AND MANAGEMENT CHALLENGE FOR SEVERAL REASONS: (1) treatment outcomes should be evaluated in relationship with a long-life expectancy, (2) pediatric patients with portal hypertension constitute an heterogeneous population, both in terms of individual characteristics and diversity of liver diseases; making comparison between treatment outcomes very difficult, (3) application of techniques and procedures developed in adult patients (v.gr. TIPS) face size limitations in small children, and (4) absence of data from well-controlled trials in children forces pediatric specialists to adapt results obtained from adult cohorts suffering from diseases such as HCV and alcoholic cirrhosis. Despite those limitations, substantial progress in the treatment of children with portal hypertension has been achieved in recent years, with better outcomes and survival. Two main factors influence our therapeutic decision: age of the patient and etiology of the liver disease. Therefore, diagnosis and treatment of complications of portal hypertension in children need to be described taking such factors into consideration. This paper summarizes current knowledge and expert opinion.

Endoscopic band ligation followed by sclerotherapy: Is it superior to sclerotherapy in children with extrahepatic portal venous obstruction?

BACKGROUND AND AIM

There is scarcity of data about children on a combination of endoscopic variceal ligation (EVL) and endoscopic sclerotherapy (EST). We assessed the efficacy of EVL followed by EST and EST alone in children with extrahepatic portal venous obstruction (EHPVO).

METHODS

From January 2000 to March 2007, 186 consecutive children (mean age 6.3 ± 4.2 years, 82% boys) with EHPVO with variceal bleeding were included. EVL followed by EST (Group I, n = 101) or EST alone (Group II, n = 60) was carried out at 3-weekly intervals until eradication. Surveillance endoscopy was done at 3 to 6-monthly intervals. In all cases, the number of sessions required to eradicate the esophageal varices, the volume of sclerosant, the complications and the endoscopic outcome on follow up were recorded.

RESULTS

Eradication was achieved in 158 of 161 (98%) children and 25 were lost to follow up. Group I required significantly fewer sessions (5.2 ± 1.8 vs 6.8 ± 2.8, P < 0.005), less sclerosant (13 ± 8.2 mL vs 30 ± 20 mL, P < 0.001) and had fewer complications (7% vs 28%, P < 0.001) as compared with Group II. On follow up (33 ± 17.6 months in Group I and 43 ± 16.7 months in Group II), there was a significant increase in the prevalence of portal hypertensive gastropathy as well as isolated gastric varices in both the groups. However, the prevalence of gastroesophageal varices decreased.

CONCLUSIONS

EVL followed by EST is better than EST alone in children with EHPVO as it requires fewer sessions and has fewer complications. However, following eradication, evolution of gastric varices and portal hypertensive gastropathy was similar in the two groups.

Upper gastrointestinal bleeding

Upper gastrointestinal bleeding is a life threatening condition in children. Common sources of upper gastrointestinal bleeding in children include variceal hemorrhage (most commonly extra-hepatic portal venous obstruction in our settings) and mucosal lesions (gastric erosions and ulcers secondary to drug intake). While most gastrointestinal bleeding may not be life threatening, it is necessary to determine the source, degree and possible cause of the bleeding. A complete and thorough history and physical examination is therefore vital. Esophagogastroduodenoscopy and colonoscopy are currently considered the first-line diagnostic procedures of choice for upper and lower GI bleeding, respectively. The goals of therapy in a child with GI bleeding should involve hemodynamic resuscitation, cessation of bleeding from source and prevention of future episodes of GI bleeding. Antacids supplemented by H2- receptor antagonists and proton pump inhibitors are the mainstay in the treatment of bleeding from mucosal lesion. For variceal bleeds, therapeutic emergency endoscopy is the treatment of choice after initial hemodynamic stabilization of the patient. Independent prognostic factors are presence of shock and co-morbidities. Underlying diagnosis, coagulation disorder, failure to identify the bleeding site, anemia and excessive blood loss are other factors associated with poor prognosis.

Intensive care management of children with acute liver failure

Acute liver failure is an uncommon condition associated with multi organ involvement, high morbidity and mortality. Etiology of acute liver failure varies with age and geographical location. Most cases of acute liver failure in India are due to infectious causes predominantly viral hepatitis. A significant group with indeterminate causation remains, despite careful investigation. The etiology of acute liver failure in infants is largely metabolic. The mainstay of management is supportive care in an intensive care unit. Monitoring of clinical and biochemical parameters is done frequently until the patient becomes stable. Mortality is predominantly due to raised intracranial pressure, infections and multi-organ failure. Liver transplant is an important life saving procedure for children with acute liver failure.

Etiology and long-term outcome of extrahepatic portal vein obstruction in children

AIM: To study the management and outcome of children with extrahepatic portal vein obstruction (EHPVO) in a whole country population.

METHODS: A nationwide multicenter retrospective case series of children with EHPVO was conducted. Data on demographics, radiographic studies, laboratory workup, endoscopic and surgical procedures, growth and development, were extracted from the patients’ charts. Characteristics of clinical presentation, etiology of EHPVO, management and outcome were analyzed.

RESULTS: Thirty patients, 13 males and 17 females, 19 (63.3%) Israeli and 11 (36.7%) Palestinians, were included in the analysis. Age at presentation was 4.8 ± 4.6 years, and mean follow-up was 4.9 ± 4.3 years. Associated anomalies were found in 4 patients. The incidence of EHPVO in Israeli children aged 0-14 years was 0.72/million. Risk factors for EHPVO were detected in 13 (43.3%) patients, including 9 patients (30%) with perinatal risk factors, and 4 patients (13.3%) with prothrombotic states: two had low levels of protein S and C, one had lupus anticoagulant, and one was homozygous for methyltetrahydrofolate reductase mutations. In 56.6% of patients, no predisposing factors were found. The most common presenting symptoms were an incidental finding of splenomegaly (43.3%), and upper gastrointestinal bleeding (40%). No differences were found between Israeli and Palestinian children with regard to age at presentation, etiology and clinical symptoms. Bleeding occurred in 18 patients (60%), at a median age of 3 years. Sclerotherapy or esophageal banding was performed in 20 patients. No sclerotherapy complications were reported. Portosystemic shunts were performed in 11 patients (36.6%), at a median age of 11 (range 3-17) years: splenorenal in 9, mesocaval in 1, and a meso-Rex shunt in 1 patient. One patient underwent splenectomy due to severe pancytopenia. Patients were followed up for a median of 3 (range 0.5-15) years. One patient died aged 3 years due to mucopolysaccharidase deficiency type III. None of the patients died due to gastrointestinal bleeding.

CONCLUSION: EHPVO is a rare disorder. The etiological factors are still mostly unknown, and the endoscopic and surgical treatment options ensure a good long-term prognosis.

Hepatic fibrosis scan for liver stiffness score measurement: a useful preendoscopic screening test for the detection of varices in postoperative patients with biliary atresia

OBJECTIVE

Even after successful Kasai portoenterostomy, progressive hepatic fibrosis in postoperative patients with biliary atresia (BA) can be associated with portal hypertension and esophageal or gastric varices. Therefore, early diagnosis and close follow-up of varices are important. We investigated the correlation between the liver stiffness scores measured by FibroScan and the presence of esophageal or gastric varices to examine the usefulness of FibroScan as a preendoscopic screening test for varices.

PATIENTS AND METHODS

A total of 49 of 81 children with BA following successful Kasai operations were enrolled in this study. FibroScan and endoscopic examination were performed prospectively.

RESULTS

There were 22 males (44.9%) and the mean age of the patients was 3.8 +/- 2.7 years. Esophageal or gastric varices were present in 30 patients (Vx group) and absent in 19 (nVx group). The mean liver stiffness score was significantly higher in the Vx group (21.35 +/- 10.31 kPa in the Vx group versus 9.75 +/- 8.61 kPa in the nVx group, P < 0.001). The optimal cutoff value of the liver stiffness score for the prediction of a varix was 9.7 kPa with a sensitivity of 0.97 and a specificity of 0.80.

CONCLUSIONS

Liver stiffness scores measured by FibroScan correlate well with the presence of esophageal or gastric varices. FibroScan is a novel, noninvasive, and useful screening method for the preendoscopic detection of varices in postoperative patients with BA.

Endoscopic treatment of gastroesophageal varices in young infants with cyanoacrylate glue: a pilot study

BACKGROUND

In children, endoscopic sclerotherapy and variceal ligation (EVL) are the most used techniques for the treatment of gastroesophageal variceal bleeding (VB). However, these techniques achieve poor results in cases of gastric variceal bleeding, and EVL is not applicable in young infants.

OBJECTIVE

Our purpose was to evaluate the feasibility, efficacy, and safety of cyanoacrylate glue injection for the treatment of gastroesophageal varices in young infants.

DESIGN

Single-center prospective study.

PATIENTS

From 2001 to 2005, 8 young infants (<or=2 years old, <or=10 kg) with portal hypertension and gastroesophageal varices underwent treatment with N-butyl-2-cyanoacrylate.

MAIN OUTCOME MEASUREMENTS

Demographic data and the results were registered and analyzed at 1, 6, and 12 months after treatment.

RESULTS

The mean age and weight were 1.3 +/- 0.42 years (range 0.8 to 1.9 years) and 8.5 +/- 1.6 kg (range 5.5 to 10 kg). Glue injection was successfully performed in all infants. The mean volume injected was 1.15 +/- 0.62 mL (range 0.5 to 2 mL). Immediate control of bleeding was achieved in all cases. Ulcer bleeding as a complication was observed in 1 case. Varices relapse with bleeding was observed in 3 of 8 (37.5%) patients after a mean of 12.5 +/- 10.6 weeks (range 5 to 20 weeks). Patients with variceal rebleeding were retreated. Varices eradication was achieved in all cases after a mean of 1.4 +/- 0.52 sessions (range 1 to 2 sessions).

LIMITATIONS

Open prospective series with a relatively small number of patients.

CONCLUSION

In young infants, the use of cyanoacrylate glue is safe and effective for the treatment of gastroesophageal VB.

Aetiology and management of extrahepatic portal vein obstruction in children: King's College Hospital experience

OBJECTIVE

To study a single-centre experience of the management of extrahepatic portal vein obstruction (EHPVO) in children during the last 3 decades.

MATERIALS AND METHODS

The medical records of 108 children (67 male, median age 4.75 years, range = 1 day-16.3 years) presenting with EHPVO between 1979 and 2005 were reviewed retrospectively.

RESULTS

Extended prothrombotic screening performed in 30 patients revealed low protein C activity (6 patients), low free protein S (2), and a positive lupus anticoagulant (1); factor V Leiden mutations and the JAK2V617F mutation were not identified. Associated congenital anomalies were found in 26 of the 108 children (24%). Clinical presentation included splenomegaly in 98 (91%) and ascites in 3 (3%). Elevation of liver enzymes and prolonged international normalized ratio were seen in 13 (12%) and 14 (13%) children, respectively. Haematological parameters of hypersplenism were present in 13 (12%). Bleeding occurred in 83 (77%) patients with a median age of 4.58 (0.02-16.37) years. On first endoscopy, oesophageal varices were present in 92 patients; of those subjects, 70 (76%) received sclerotherapy, 5 (5%) had band ligation, and 16 (17%) received both. Complications of endoscopy occurred in 34 (37%) patients: oesophageal ulcers in 16, oesophageal stricture in 10, both in 7, and erosive gastritis in 1. Seventeen (16%) children underwent shunt surgery for uncontrolled bleeding at a median age of 9.7 (5.2-23.7) years.

CONCLUSIONS

The aetiology of EHPVO in the majority of patients remains unknown. Sclerotherapy and banding are effective treatments for bleeding varices with good long-term outcome. Procoagulant state is an infrequent cause of EHPVO in children.

Etiological spectrum of esophageal varices due to portal hypertension in Indian children: is it different from the West?

BACKGROUND AND AIM

Information about portal hypertension (PHT) in children is meagre. We therefore studied the spectrum and outcome of PHT in children (<or=14 years of age) over a period of 9 years.

METHODS

PHT was diagnosed on endoscopy (presence of varices) in 517 cases during the study period. The diagnosis of extrahepatic portal venous obstruction (EHPVO) and Budd-Chiari Syndrome (BCS) were made on the basis of ultrasound examination. Cirrhosis was diagnosed on the basis of clinical, biochemical, ultrasound, and liver biopsy (whenever feasible). Noncirrhotic portal fibrosis (NCPF) and congenital hepatic fibrosis (CHF) were diagnosed on liver biopsy. Endoscopic sclerotherapy (EST) was done in all the patients who presented with variceal bleeding and surgery was performed whenever indicated.

RESULTS

Causes of PHT included EHPVO in 54%, cirrhosis in 39%, CHF in 3%, NCPF in 2%, and BCS in 2%. Of these, 279 (54%) patients presented with upper gastrointestinal bleeding and this group comprised of EHPVO in 85%, cirrhosis in 10%, CHF in 2.5%, NCPF in 2%, and BCS in 1%. Bleeding was the presenting feature in 85% of EHPVO cases and in 13% of cirrhosis cases. In EHPVO cases, variceal eradication was achieved in 95% of cases with a mean 5 +/- 2.4 EST sessions. Surgery was required in 24 cases of EHPVO. Mortality due to bleeding was 1.7% in EHPVO and 30% in cirrhosis.

CONCLUSIONS

EHPVO and cirrhosis are the two major causes of PHT in children. However, predominant cause of variceal bleeding is EHPVO. EST is an effective method of treatment in EHPVO.

Clinical and laboratory predictors of esophageal varices in children and adolescents with portal hypertension syndrome

OBJECTIVES

To determine the clinical and laboratory parameters that may predict the presence of esophageal varices in children and adolescents with portal hypertension.

PATIENTS AND METHODS

Overall, 111 patients with portal hypertension and no previous history of digestive bleeding underwent esophagogastroduodenoscopy for detection of esophageal varices. A univariate analysis initially was carried out, followed by a logistic regression analysis to identify the independent variables associated with the presence of esophageal varices. Sensitivity and specificity rates, positive predictive value, negative predictive value, and the accuracy of the predictive variables identified among cirrhotic patients were calculated with the esophagogastroduodenoscopy as the reference test.

RESULTS

Sixty percent of patients had esophageal varices on the first esophagogastroduodenoscopy. Patients with portal vein thrombosis and congenital hepatic fibrosis were 6.15-fold more likely to have esophageal varices than cirrhotic patients. When we analyzed 85 cirrhotic patients alone, splenomegaly and hypoalbuminemia remained significant indicators of esophageal varices. Only spleen enlargement showed appropriate sensitivity and negative predictive value (97.7% and 91.7%, respectively) to be used as a screening test for esophageal varices among cirrhotic patients.

CONCLUSIONS

In reference services and research protocols, endoscopic screening should be performed in all patients with portal vein thrombosis and congenital hepatic fibrosis. Among cirrhotic patients, the indication should be conditioned to clinical evidence of splenomegaly or hypoalbuminemia. For clinicians, the recommendation is to emphasize the orientations given to guardians of patients with portal vein thrombosis and congenital hepatic fibrosis as to the risk of digestive bleeding. Cirrhotic patients with hypoalbuminemia and splenomegaly should receive the same orientations.

Emergency endoscopy in children

Endoscopy in children has developed along with pediatric gastroenterology over the last four decades. Introduction of endoscopic techniques in adults precedes application in children, and pediatric endoscopists do fewer procedures than their adult counterparts whether routine or as an emergency. Training for pediatric endoscopists therefore needs to be thorough. This article in particular highlights developments in pediatric gastroenterology of importance to emergency procedures.

Pediatric gastroesophageal varices: treatment strategy and long-term results

BACKGROUND/PURPOSE

There are various treatment strategies for gastroesophageal varices in children. We studied the therapeutic value of endoscopic variceal clipping (EVC) and ligation (EVL).

METHODS

Four hundred ninety-nine endoscopic examinations performed between 1991 and 2005 were retrospectively analyzed. F2 and F3 varices with red color signs on follow-up endoscopy were treated with prophylactic EVC. In variceal rupture cases, EVC and EVL were used in combination.

RESULTS

Eighty-two prophylactic EVCs were done, and variceal progression was prevented in 89.9%. However, some patients had persistent red color signs and required frequent EVC. Ten emergent procedures were done for variceal rupture, and, in 4 cases, EVL was used to arrest massive variceal bleeding. Five patients developed bleeding during follow-up cause by rupture of gastric fundal varices, which probably had been aggravated by prior treatment for esophageal varices.

CONCLUSIONS

The control of gastroesophageal varices by routine EVC was satisfactory. However, ruptures during follow-up suggested the importance of controlling gastric fundal varices. Endoscopic variceal ligation is a simple, effective, and safe treatment tool, particularly for ruptured varices. However, it is difficult to treat gastric fundal varices with EVL; this disadvantage of EVL can be overcome by the concomitant use of EVC.

Band ligation plus sclerotherapy versus sclerotherapy alone in children with extrahepatic portal venous obstruction

Although endoscopic band ligation (EVL) plus sclerotherapy (EST) has shown to be superior to any individual method, there is no study in children. We therefore analyzed our experience of EST and EVL + EST in children with extrahepatic portal venous obstruction (EHPVO). Over a period of 8 years, 136 children who presented with a history of recent variceal bleeding due to EHPVO were studied; 30 of them received EVL + EST and 106 received EST alone. In the EVL + EST group, after the first session of EVL, EST was done three times weekly until variceal eradication was achieved. The mean age of these children was 7 +/- 3.6 years with a male-to-female ratio of 2.6:1. The rate of eradication was comparable in both groups (100% in EVL + EST and 96% in EST). However, EVL + EST group required a significantly fewer sessions and lower volume of sclerosant (2 +/- 1 vs. 4.4 +/- 2 sessions, P < 0.001 and 3.1 +/- 2 mL versus 7.5 +/- 4 mL, P < 0.001 respectively). There were significantly less complications in EVL + EST group (10% vs. 36%, P < 0.01). Over a mean follow-up of 27 months, varices recurred in 6.6% and 10% cases, respectively. EVL + EST is a better method in the treatment of esophageal varices in children with EHPVO than EST alone, as it required fewer session and had fewer complication.

Frequency of gastropathy and gastric varices in children with extrahepatic portal venous obstruction treated with sclerotherapy

BACKGROUND

There are limited reports of the effect of endoscopic sclerotherapy (EST) on portal hypertensive gastropathy (PHG) and gastric varices (GV) in children with extrahepatic portal venous obstruction (EHPVO). We have studied the prevalence of PHG and GV in children with EHPVO and assessed the effect of EST on them on long-term follow-up.

METHODS

From January 1992 to June 2002, consecutive children presenting with variceal bleeding due to EHPVO were included in this study. All children underwent EST at presentation and at 2-3 week intervals thereafter. During each session of endoscopy, gastric mucosa and fundus of the stomach was screened carefully to detect PHG and GV. Gastric varices were classified as gastroesophageal (GOV) and isolated gastric varices (IGV).

RESULTS

In total, 274 cases of EHPVO were managed during the study period. The mean age was 7.4 +/- 3.5 years with a male to female ratio of 2.3:1. Of these 274 cases, 186 completed the EST program (study population), 60 were lost to follow-up, five died and 23 underwent surgery. At presentation (n = 274) 27% cases had PHG (3.6% severe) and 68.6% had GV (GOV 66.8%, IGV 1.8%). Following EST (n = 186) there was a significant (P < 0.001) decrease in GOV (45% from 64%) but an increase in IGV (14% from 1%) and PHG (51.6% from 24.7%). There was also a significant increase in severe PHG (15.6% from 3.2%, P < 0.05). On follow-up (mean follow-up 38 +/- 30 months) 19% children with IGV bled while none with PHG bled.

CONCLUSIONS

Portal hypertensive gastropathy and gastric varices are quite common in children with EHPVO. Following EST, there is a chance of developing isolated gastric varices.

Treatment of Pediatric Cholestatic Liver Disease

Cholestatic liver disease affects a small percentage of children, but therapy results in millions of healthcare dollars being spent each year. Close monitoring of nutritional status, pruritus, and complications from portal hypertension should improve the patient's quality of life and survival without liver transplantation. Other comorbid conditions, such as cardiac or renal disease, must also be integrated into the care plan and will affect the overall prognosis of the patient. Portal hypertension leads to ascites, variceal hemorrhage, and infection, which can result in significant mortality if not promptly recognized and treated. Surgical shunts are being used less because the expertise to perform endoscopic sclerotherapy and endoscopic band ligation is available at most medical centers. However, many cholestatic diseases, including biliary atresia, progressive familial intrahepatic cholestasis (PFIC) I, II, and III, and Alagille syndrome, may still require liver transplantation (Table 1). The cost of this procedure can exceed several hundred thousand dollars per patient, without including the annual costs of immunosuppressant therapy and medical monitoring. Meticulous medical management of nutrition and the sequelae of portal hypertension may prolong survival and reduce the potential morbidity and mortality of liver transplantation.

Endoscopic ligation of esophageal varices for prophylaxis of first bleeding in children and adolescents with portal hypertension: preliminary results of a prospective study

BACKGROUND/PURPOSE

Endoscopic variceal ligation (EVL) is effective in controlling rebleeding from esophageal varices in children, but there is no data on the use of EVL to prevent initial bleeding. The objective of this study was to prospectively evaluate the efficacy of EVL in preventing the first hemorrhage from esophageal varices in children.

METHODS

Thirty-seven children with portal hypertension (22 liver cirrhosis, 15 portal vein thrombosis), aged 4 to 17 years (M = 9.5 +/- 4.4 years) were included in the study. The criteria for inclusion were (1) no previous variceal bleeding; (2) the presence of esophageal varices classified grade II or more, and (3) their enlargement by at least I grade after 6 months of observation without endoscopic treatment or appearance of endoscopic signs of high bleeding risk. A Multi-Band Ligator was used, and 2 to 6 bands were fixed under general anesthesia during one procedure depending on the number and size of varices. Follow-up examinations were performed every 3 months, repeating the procedure if necessary. In total, 75 procedures of EVL were performed, from one to 5 in each patient

RESULTS

Four patients underwent liver transplantation before eradication of varices. Two others were excluded from the observation because of lack of compliance to the protocol. Of the remaining 31 patients, eradication of varices was achieved in 28 children (90.3%) after 2.0 EVL sessions performed at 3-month intervals. The average time of follow-up after cessation of treatment is 16 months. No bleeding from varices occurred in any child during or after treatment. There were no differences in results between children with liver cirrhosis and portal vein thrombosis. Development of hypertensive gastropathy was observed in 2 children with one episode of bleeding. Recurrence of varices without bleeding occurred in 3 children after 12, 13, and 28 months from eradication.

CONCLUSIONS

The study results confirmed that endoscopic variceal ligation is a safe and highly effective procedure in children with portal hypertension, regardless of its etiology. Eradication of esophageal varices was followed by 16 months free of bleeding. Prolonged observation is mandatory to conclude if preventive EVL influences the natural history of disease and diminishes the risk of first bleeding onset.

Endoscopic sclerotherapy in children: experience with 257 cases of extrahepatic portal venous obstruction

BACKGROUND

Endoscopic sclerotherapy often is used to treat variceal bleeding in children with extrahepatic portal hypertension, but published data are limited. The role of endoscopic sclerotherapy in a large number of children with extrahepatic portal hypertension was evaluated.

METHODS

Consecutive children presenting with variceal bleeding because of extrahepatic portal hypertension were included in this study. All children underwent endoscopic sclerotherapy with absolute alcohol at presentation and at 2-week to 3-week intervals thereafter, until variceal eradication was achieved. Follow-up endoscopy was performed at 3 months after eradication and then every 6 months thereafter.

RESULTS

A total of 257 patients with extrahepatic portal hypertension were managed from January 1992 to December 2001. Of these, 50 were lost to follow-up before eradication was achieved, leaving 207 patients (144 boys, 63 girls; mean age at presentation, 7 [SD 3.5] years) for whom evaluation was complete. Of the 207 patients, 5 died of bleeding, 23 underwent surgery, and 6 are still undergoing endoscopic treatment. Varices were successfully eradicated in 165 of 173 cases (95%) after a mean of 4.5 (1.9) endoscopic sclerotherapy sessions (mean volume of sclerosant, 8 [4] mL). Complications encountered were ulcer (17%), stricture (18%), and perforation (1.4%). Interval bleeding before eradication was encountered in 10.6% of cases. At a mean follow-up of 36 (29) months, varices had recurred in 17% patients, but only 3 of them had recurrent bleeding.

CONCLUSIONS

Endoscopic sclerotherapy effectively eradicates varices in children with extrahepatic portal hypertension, with an acceptable complication rate. On long-term follow-up, recurrent bleeding after eradication is rare.