Endoscopic ligation compared with sclerotherapy for bleeding esophageal varices in children with extrahepatic portal venous obstruction

Clinical, radiologic, and endoscopic characteristics upon diagnosis of patients with prehepatic portal hypertension at the Instituto Nacional de Pediatría from 2001 to 2011

BACKGROUND

Prehepatic portal hypertension in children can be asymptomatic for many years. Once diagnosed, the therapeutic measures (pharmacologic, endoscopic, and surgical) are conditioned by the specific characteristics of each patient. In Mexico, there are no recorded data on the incidence of the disease and patient characteristics.

AIMS

To determine the main clinical, radiologic, and endoscopic characteristics upon diagnosis of these patients at the Instituto Nacional de Pediatría within the time frame of January 2001 and December 2011.

METHODS

A cross-sectional, retrolective, descriptive, and observational study was conducted in which all the medical records of the patients with portal hypertension diagnosis were reviewed.

RESULTS

There was a greater prevalence of prehepatic etiology (32/52) (61.5%) in the portal hypertension cases reviewed. Males (62.5%) predominated and 11 of the 32 patients were under 4 years of age. The primary reason for medical consultation was upper digestive tract bleeding with anemia (71.9%) and the main pathology was cavernomatous degeneration of the portal vein (65.6%). Splenoportography was carried out on 17 of the 32 patients. A total of 65.5% of the patients received the combination therapy of propranolol and a proton pump inhibitor. Initial endoscopy revealed esophageal varices in 96.9% of the patients, 12 of whom presented with gastroesophageal varices. Congestive gastropathy was found in 75% of the patients. The varices were ligated in 8 cases, sclerotherapy for esophageal varices was carried out in 5 cases (15.6%), and sclerotherapy for gastric varices was performed in 2 patients. Seventeen patients (53.1%) underwent portosystemic diversion: 10 of the procedures employed a mesocaval shunt and 7 a splenorenal shunt. Nine patients (28.1%) underwent total splenectomy.

CONCLUSIONS

The primary cause of the disease was cavernomatous degeneration of the portal vein; it was predominant in males and the first symptom was variceal bleeding.

Non-cirrhotic portal hypertension

Non-cirrhotic portal hypertension (NCPH) encompasses a wide range of disorders, primarily vascular in origin, presenting with portal hypertension (PHT), but with preserved liver synthetic functions and near normal hepatic venous pressure gradient (HVPG). Non-cirrhotic portal fibrosis/Idiopathic PHT (NCPF/IPH) and extrahepatic portal venous obstruction (EHPVO) are two prototype disorders in the category. Etiopathogenesis in both of them centers on infections and prothrombotic states. Presentation and management strategies focus on repeated well tolerated episodes of variceal bleed and moderate to massive splenomegaly and other features of PHT. While the long-term prognosis is generally good in NCPF, portal biliopathy and parenchymal extinction after prolonged PHT makes outcome somewhat less favorable in EHPVO. While hepatic schistosomiasis, congenital hepatic fibrosis and nodular regenerative hyperplasia have their distinctive features, they often present with NCPH.

Modifications in endoscopic practice for pediatric patients

We recommend that endoscopy in children be performed by pediatric-trained endoscopists whenever possible. We recommend that adult-trained endoscopists coordinate their services with pediatricians and pediatric specialists when they are needed to perform endoscopic procedures in children. We recommend that endoscopy be performed within 24 hours in symptomatic pediatric patients with known or suspected ingestion of caustic substances. We recommend emergent foreign-body removal of esophageal button batteries, as well as 2 or more rare-earth neodymium magnets. We recommend that procedural and resuscitative equipment appropriate for pediatric use should be readily available during endoscopic procedures. We recommend that personnel trained specifically in pediatric life support and airway management be readily available during sedated procedures in children. We recommend the use of endoscopes smaller than 6 mm in diameter in infants and children weighing less than 10 kg. We recommend the use of standard adult duodenoscopes for performing ERCP in children who weigh at least 10 kg. We recommend the placement of 12F or 16F percutaneous endoscopic gastrostomy tubes in children who weigh less than 50 kg.

Non-cirrhotic portal hypertension - diagnosis and management

NCPH is a heterogeneous group of liver disorders of vascular origin, leading to PHT with near normal HVPG. NCPF/IPH is a disorder of young adults or middle aged women, whereas EHPVO is a disorder of childhood. Early age acute or recurrent infections in an individual with thrombotic predisposition constitute the likely pathogenesis. Both disorders present with clinically significant PHT with preserved liver functions. Diagnosis is easy and can often be made clinically with support from imaging modalities. Management centers on control and prophylaxis of variceal bleeding. In EHPVO, there are additional concerns of growth faltering, portal biliopathy, MHE and parenchymal dysfunction. Surgical shunts are indicated in patients with failure of endotherapy, bleeding from sites not amenable to endotherapy, symptomatic hypersplenism or symptomatic biliopathy. Persistent growth failure, symptomatic and recurrent hepatic encephalopathy, impaired quality of life or massive splenomegaly that interferes with daily activities are other surgical indications. Rex-shunt or MLPVB is the recommended shunt for EHPVO, but needs proper pre-operative radiological assessment and surgical expertise. Both disorders have otherwise a fairly good prognosis, but need regular and careful surveillance. Hepatic schistosomiasis, CHF and NRH have similar presentation and comparable prognosis.

Primary extrahepatic portal vein obstruction in adults: a single center experience

BACKGROUND

Extrahepatic portal venous obstruction (EHPVO) is a heterogenous disease with regards to etiology, pathogenesis, age, and geographical location. This study analyzed our experience with EHPVO in adults aged >20 years. EHPVO associated with pancreatitis and abdominal lymph node tuberculosis compressing the portal vein was excluded.

METHODS

Retrospective analysis of the hospital database from January 2000 to December 2009 was done. All patients with liver disease who are attending our department were also prospectively evaluated with Doppler ultrasound for the portal venous system to study the prevalence of EHPVO. Clinical, biochemical, and imaging findings; work up for thrombophilia; treatment given; and follow up were evaluated.

RESULT

In the retrospective analysis, primary EHPVO in adults was seen in 108/10,095 (1 %), and in the prospective analysis, it was seen in 16/2,188 (0.73 %). The main clinical presentations were abdominal pain and variceal bleed. Imaging findings included portal cavernoma, portal biliopathy, gallbladder calculi, collaterals, and ascites. The major causative factors identified were hyperhomocysteinemia, antiphospholipid antibodies, and myeloproliferative disorders, while, in a third of patients, none of these risk factors could be identified. Twelve patients were subjected to surgery, while the remaining patients were managed either by medical, endoscopic, or interventional radiological techniques. More than 2 years of follow up was available in 90 patients; two patients died due to uncontrolled bleeding, seven patients required surgery, seven patients showed deterioration in liver function, and one patient developed hepatocellular carcinoma. In the prospective study, three patients were subjected to surgery, and the others were managed medically.

CONCLUSION

Primary EHPVO is an uncommon cause of portal hypertension in adults in India, and its etiological spectrum is comparable to the West.

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.

An update on pediatric endoscopy

Advances in endoscopy and anesthesia have enabled gastrointestinal endoscopy for children since 1960. Over the past decades, the number of endoscopies has increased rapidly. As specialized teams of pediatric gastroenterologists, pediatric intensive care physicians and pediatric endoscopy nurses are available in many medical centers, safe and effective procedures have been established. Therefore, diagnostic endoscopies in children are routine clinical procedures. The most frequently performed endoscopies are esophagogastroduodenoscopy (EGD), colonoscopy and endoscopic retrograde cholangiopancreaticography (ERCP). Therapeutic interventions include variceal bleeding ligation, foreign body retrieval and percutaneous endoscopic gastrostomy. New advances in pediatric endoscopy have led to more sensitive diagnostics of common pediatric gastrointestinal disorders, such as Crohn's disease, ulcerative colitis and celiac disease; likewise, new diseases, such as eosinophilic esophagitis, have been brought to light.Upcoming modalities, such as capsule endoscopy, double balloon enteroscopy and narrow band imaging, are being established and may contribute to diagnostics in pediatric gastroenterology in the future.

New approaches to the autosomal recessive polycystic kidney disease patient with dual kidney-liver complications

Improved neonatal medical care and renal replacement technology have improved the long-term survival of patients with ARPKD. Ten-yr survival of those surviving the first year of life is reported to be 82% and is continuing to improve further. However, despite increases in overall survival and improved treatment of systemic hypertension and other complications of their renal disease, nearly 50% of survivors will develop ESRD within the first decade of life. In addition to renal pathology, patients with ARPKD develop ductal plate malformations with cystic dilation of intra- and extrahepatic bile ducts resulting in CHF and Caroli syndrome. Many patients with CHF will develop portal hypertension with resulting esophageal varices, splenomegaly, hypersplenism, protein losing enteropathy, and gastrointestinal bleeding. Management of portal hypertension may require EBL of esophageal varices or porto-systemic shunting. Complications of hepatic involvement can include ascending cholangitis, cholestasis with malabsorption of fat-soluble vitamins, and rarely benign or malignant liver tumors. Patients with ARPKD who eventually reach ESRD, and ultimately require kidney transplantation, present a unique set of complications related to their underlying hepato-biliary disease. In this review, we focus on new approaches to these challenging patients, including the indications for liver transplantation in ARPKD patients with severe chronic kidney disease awaiting kidney transplant. While survival in patients with ARPKD and isolated kidney transplant is comparable to that of age-matched pediatric patients who have received kidney transplants due to other primary renal diseases, 64-80% of the mortality occurring in ARPKD kidney transplant patients is attributed to cholangitis/sepsis, which is related to their hepato-biliary disease. Recent data demonstrate that surgical mortality among pediatric liver transplant recipients is decreased to <10% at one yr. The immunosuppressive regimen used for kidney transplant recipients is adequate for most liver transplant recipients. We therefore suggest that in a select group of ARPKD patients with recurrent cholangitis or complications of portal hypertension, combined liver-kidney transplant is a viable option. Although further study is necessary to confirm our approach, we believe that combined liver-kidney transplantation can potentially decrease overall mortality and morbidity in carefully selected ARPKD patients with ESRD and clinically significant CHF.

Assessment of risk of bleeding from esophageal varices during management of biliary atresia in children

OBJECTIVES

The management of esophageal varices (EV) in children experiencing biliary atresia (BA) remains controversial. Recent studies in children proposed initiating a prophylactic treatment in patients with severe (grade III) EV and/or EV associated with red color signs. Our study was aimed at assessing the risk of bleeding from EV in a series of patients with BA, identifying risk factors for bleeding to develop a predictive model of bleeding.

METHODS

This was a retrospective study including 83 eligible patients with BA. Clinical, ultrasonographic, endoscopic, and laboratory parameters were studied from the beginning of medical management up to the occurrence of upper gastrointestinal bleeding. In patients not presenting any bleeding, data were analyzed until liver transplantation, endoscopic treatment of EV was performed, or last follow-up. Risk factors were investigated using univariate and multivariate statistical analyses.

RESULTS

Seventeen of 83 patients (20%) presented gastrointestinal bleeding, with a median age of 9.5 months (6-50 months). In univariate and multivariate analyses, high-grade EV, red color signs on endoscopic examination, and low fibrinogen levels, at first endoscopy, were identified as risk factors for bleeding. When tested in >10,000 different models, these 3 variables appeared to play the most significant role in predicting bleeding.

CONCLUSIONS

Our study confirmed that grade III EV and red color signs are risk factors for bleeding in patients followed up for BA. We identified low fibrinogen levels as an additional risk factor. The relevance of these 3 factors to predict bleeding from EV requires validation in a prospective study.

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.

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.

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.

Variceal recurrence, rebleeding rates and alterations in clinical and laboratory parameters following post-variceal obliteration using endoscopic sclerotherapy

OBJECTIVE

To study the rates of variceal recurrence and rebleeding following sclerotherapy and its effect on clinical and laboratory parameters in patients with portal hypertension.

METHODS

A total of 237 patients with portal hypertension together with esophageal variceal bleeding were included in the study. There were 138 patients with cirrhosis (group I), 42 with non-cirrhotic portal fibrosis (group II), and 57 with extrahepatic portal vein obstruction (group III). Baseline data and post-obliteration follow-up for rebleeding rates and changes in clinical and laboratory parameters were recorded.

RESULTS

In all, 106 patients in group I, 31 in group II and 43 in group III experienced obliteration of varices. The recurrence of grade II varices occurred in 17 patients (9.4%) during a mean period of 9 months. Rebleeding from varices was observed in 4 patients (3.8%) in group I and 1 (3.2%) in group II, while none in group III experienced rebleeding. There was a significant improvement in ascites, jaundice, liver status, international normalized ratio and platelet count in group I patients after variceal eradication (P < 0.05). The main cause of death in the cirrhotic patients was active liver disease but not rebleeding.

CONCLUSIONS

Following obliterative endoscopic sclerotherapy, rates of recurrence and rebleeding were significantly low when patients are kept under close observation. Disappearance of varices or reduction of variceal size improves the liver status in surviving cirrhotic patients.

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.

Medical management of esophageal varices and portal hypertension in children

Portal hypertension (PH) is a common complication of chronic liver disease in children and represents a cause of morbidity and, rarely, mortality in this group of patients. Although often self-limiting, gastrointestinal bleeding in this setting is regarded as a frightening event by patients and carers, giving the impression of impending death. Therefore, it is important to raise the awareness on the natural history of PH in children, the utility of tools that help preventing and managing acute bleeding, and the signs predicting a poor outcome, thus indicating surgery. There is lack of data on the ability of endoscopy screening, endoscopic treatment of varices, and use of nonselective β-blockers to alter the outcome of PH in children; major efforts should be made to avoid such treatments empirically and promote multicenter trials instead. Nevertheless, such approach should be balanced against the need of offering the best care to children with PH. In this review, we discuss the advances made in the management of PH in children and compare it with the larger adult experience. A rational approach to acute gastrointestinal bleeding is proposed along with an algorithm suggesting a stepwise protocol to manage children with esophageal varices in the long-term, with some hints on possible future studies.

Portal hypertension in children: expert pediatric opinion on the report of the Baveno v Consensus Workshop on Methodology of Diagnosis and Therapy in Portal Hypertension

Complications of portal hypertension in children lead to significant morbidity and are a leading indication for consideration of liver transplantation. Approaches to the management of sequelae of portal hypertension are well described for adults and evidence-based approaches have been summarized in numerous meta-analyses and conferences. In contrast, there is a paucity of data to guide the management of complications of portal hypertension in children. An international panel of experts was convened on April 8, 2011 at The Children's Hospital of Pittsburgh of UPMC to review and adapt the recent report of the Baveno V Consensus Workshop on the Methodology of Diagnosis and Therapy in Portal Hypertension to the care of children. The opinions of that expert panel are reported.

Management of hepatic vascular diseases

Primary damage to hepatic vessels is rare. (i) Hepatic arterial disorders, related mostly to iatrogenic injury and occasionally to systemic diseases, lead to ischemic cholangiopathy. (ii) Hepatic vein or inferior vena cava thrombosis, causing primary Budd-Chiari syndrome, is related typically to a combination of underlying prothrombotic conditions, particularly myeloproliferative neoplasms, factor V Leiden, and oral contraceptive use. The outcome of Budd-Chiari syndrome has markedly improved with anticoagulation therapy and, when needed, angioplasty, stenting, TIPS, or liver transplantation. (iii) Extrahepatic portal vein thrombosis is related to local causes (advanced cirrhosis, surgery, malignant or inflammatory conditions), or general prothrombotic conditions (mostly myeloproliferative neoplasms or factor II gene mutation), often in combination. Anticoagulation at the early stage prevents thrombus extension and, in 40% of the cases, allows for recanalization. At the late stage, gastrointestinal bleeding related to portal hypertension can be prevented in the same way as in cirrhosis. (iv) Sinusoidal obstruction syndrome (or venoocclusive disease), caused by agents toxic to bone marrow progenitors and to sinusoidal endothelial cells, induces portal hypertension and liver dysfunction. Decreasing the intensity of myeloablative regimens reduces the incidence of sinusoidal toxicity. (v) Obstruction of intrahepatic portal veins (obliterative portal venopathy) can be associated with autoimmune diseases, prothrombotic conditions, or HIV infection. The disease can eventually be complicated with end-stage liver disease. Extrahepatic portal vein obstruction is common. Anticoagulation should be considered. (vi) Nodular regenerative hyperplasia is induced by the uneven perfusion due to obstructed sinusoids, or portal or hepatic venules. It causes pure portal hypertension.

Treatment of portal hypertension

Portal hypertension is the main complication of cirrhosis and is defined as an hepatic venous pressure gradient (HVPG) of more than 5 mmHg. Clinically significant portal hypertension is defined as HVPG of 10 mmHg or more. Development of gastroesophageal varices and variceal hemorrhage are the most direct consequence of portal hypertension. Over the last decades significant advancements in the field have led to standard treatment options. These clinical recommendations have evolved mostly as a result of randomized controlled trials and consensus conferences among experts where existing evidence has been reviewed and future goals for research and practice guidelines have been proposed. Management of varices/variceal hemorrhage is based on the clinical stage of portal hypertension. No specific treatment has shown to prevent the formation of varices. Prevention of first variceal hemorrhage depends on the size/characteristics of varices. In patients with small varices and high risk of bleeding, non-selective β-blockers are recommended, while patients with medium/large varices can be treated with either β-blockers or esophageal band ligation. Standard of care for acute variceal hemorrhage consists of vasoactive drugs, endoscopic band ligation and antibiotics prophylaxis. Transjugular intrahepatic portosystemic shunt (TIPS) is reserved for those who fail standard of care or for patients who are likely to fail (“early TIPS”). Prevention of recurrent variceal hemorrhage consists of the combination of β-blockers and endoscopic band ligation.

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 management of portal hypertension

Cirrhosis is the leading cause of portal hypertension worldwide, with the development of bleeding gastroesophageal varices being one of the most life-threatening consequences. Endoscopy plays an indispensible role in the diagnosis, staging, and prophylactic or active management of varices. With the expected future refinements in endoscopic technology, capsule endoscopy may one day replace traditional gastroscopy as a diagnostic modality, whereas endoscopic ultrasound may more precisely guide interventional therapy for gastric varices.

Primary prophylaxis of variceal hemorrhage in children with portal hypertension: a framework for future research

Nonselective β-blocker therapy and endoscopic variceal ligation reduce the incidence of variceal hemorrhage in cirrhotic adults, but their use in children is controversial. There are no evidence-based recommendations for the prophylactic management of children at risk of variceal hemorrhage due to the lack of appropriate randomized controlled trials. In a recent gathering of experts at the American Association for the Study of Liver Diseases annual meeting, significant challenges were identified in attempting to design and implement a clinical trial of primary prophylaxis in children using either of these therapies. These challenges render such a trial unfeasible, primarily due to the large sample size required, inadequate knowledge of appropriate dosing of β-blockers, and difficulty in recruiting to a trial of endoscopic variceal ligation. Pediatric research should focus on addressing questions of natural history and diagnosis of varices, prediction of variceal bleeding, optimal approaches to β-blocker and ligation therapy, and alternative study designs to explore therapeutic efficacy in children.

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.

Management of portal hypertension in children

Management of portal hypertension in children has evolved over the past several decades. Portal hypertension can result from intrahepatic or extrahepatic causes. Management should be tailored to the child based on the etiology of the portal hypertension and on the functionality of the liver. The most serious complication of portal hypertension is gastroesophageal variceal bleeding, which has a mortality of up to 30%. Initial treatment of bleeding focuses on stabilizing the patient. Further treatment measures may include endoscopic, medical, or surgical interventions as appropriate for the child, depending on the cause of the portal hypertension. β-Blockers have not been proven to effectively prevent primary or secondary variceal bleeding in children. Sclerotherapy and variceal band ligation can be used to stop active bleeding and can prevent bleeding from occurring. Transjugular intrahepatic portosystemic shunts and surgical shunts may be reserved for those who are not candidates for transplant or have refractory bleeding despite medical or endoscopic treatment.

Measurement of hepatic vein pressure gradient in children with chronic liver diseases

BACKGROUND & AIMS

The aim of this study is to present our preliminary experience with Hepatic Vein Pressure Gradient (HVPG) measurements in pediatric patients with chronic liver disease.

METHODS

Institutional review board approval was obtained. HVPG was measured in 20 pediatric patients, mean age 82+/-54 months, with chronic liver disease, without extrahepatic portal vein obstruction. In nine patients the end-stage liver disease was secondary to biliary atresia; in the remaining 11, to various causes. Eleven patients had esophageal varices at endoscopy, 14 had perigastric and periesophageal collaterals at imaging scan, three had ascites, 12 had low platelet count, and all had splenomegaly.

RESULTS

Hepatic vein catheterization was technically possible in all patients without complications. HVPG values were elevated in all but three patients, ranging between 2 and 33 mmHg (mean 11.3+/-7.2 mmHg), thus indicating a sinusoidal component in portal hypertension. A salient finding was the presence of hepatic venovenous shunts in 7 out of 9 patients with biliary atresia; however, the HVPG could still be measured distal to the shunts, but in three patients (with an HVPG of 8 mmHg) it was determined in an area with a small venovenous communication still visible, therefore underestimating the actual portal pressure gradient. No venovenous shunts were detected in the non-biliary atresia patients.

CONCLUSIONS

HVPG is a feasible procedure in pediatric patients. Patients with biliary atresia very frequently have communicating vessels between hepatic veins. This hitherto unacknowledged finding can lead to the underestimation of portal pressure by HVPG measurement.

Quality of life in children managed for extrahepatic portal venous obstruction

OBJECTIVES

There are no studies on health-related quality of life (HRQOL) in children with extrahepatic portal venous obstruction (EHPVO). The present study evaluated the QOL in children with EHPVO, prevariceal and postvariceal esophageal variceal eradication, and postsurgery in comparison with healthy controls.

METHODS

Children with EHPVO and variceal bleeding were divided into 3 groups: group A, before variceal eradication (n = 50); group B, after variceal eradication (n = 50); and group C, after surgery (n = 12). Group D comprised healthy children (n = 50). Clinical details and investigations were recorded. The Pediatric Quality of Life Inventory parent-proxy HRQOL questionnaire was used for assessment of QOL.

RESULTS

Compared with controls, patients with EHPVO in groups A, B, and C had lower median QOL scores in physical, emotional, social, and school functioning health domains. Esophageal variceal eradication had no significant effect on QOL (median total QOL score pre- and postvariceal eradication of 87.5 vs 86.3). Increasing size of spleen (mild 92.5, moderate 88.2, and severe 76.2; P < 0.001), presence of hypersplenism (90 vs 73.7, P = 0.001), and growth retardation (90 vs 82.5, P = 0.04) caused significant reduction of the total QOL score. On multivariate regression analysis, splenic size and growth retardation were found to be independent predictors that affect the QOL. After surgery, a trend toward improvement in physical, psychosocial, and total QOL scores was present, but it was not significant.

CONCLUSIONS

Children with EHPVO have a poor QOL that is not affected by variceal eradication. Splenomegaly and growth retardation significantly affect the HRQOL. A trend toward improvement of QOL scores is observed in the postsurgery group.

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.

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.

Modified technique of meso-Rex shunt in case of insufficient length of the jugular vein graft

Meso-Rex shunt (MRS) can relieve portal hypertension and restore a physiological portal flow in patients with portal vein thrombosis. We describe a technical variant where the autologous internal jugular vein (IJV) was too short to bridge the superior mesenteric vein (SMV) and the Rex recessus.

PATIENT

A 15-year-old boy with portal cavernoma had several episodes of gastrointestinal bleeding despite repeated sclerotherapy. Preoperative assessment, including retrograde transjugular portography, showed persistent esophageal and gastric varices, severe hypertensive gastropathy, obstructed portal vein, patent SMV and splenomesenteric confluence, patent intrahepatic portal branches, and normal transhepatic pressure gradient. An MRS was planned. The left IJV was retrieved from its infracranial part to its confluence with subclavian vein. After performing the Rex recessus to IJV graft anastomosis, the IJV graft proved to be too short for classical end-to-side anastomosis onto the SMV. After clamp testing showing good tolerance of the small bowel, the proximal jejunal branches of the SMV were tied, the proximal SMV was mobilized and transsected 4 cm below the pancreas, and an end-to-end anastomosis between SMV and IJV was performed. Portal pressure decreased from 23 to 13 mm Hg, and intraoperative Ultra Sound Doppler (US Doppler) showed good flows in the shunt. Postoperative course was uneventful, and 1 year after surgery, the child is clinically well, off medication, with a patent shunt, and no portal hypertension.

CONCLUSION

This modified MRS technique may be useful when the autologous IJV graft is too short, avoiding the need for prosthetic conduits and prolonged postoperative anticoagulation.

Vascular disorders of the liver

This guideline has been approved by the American Association for the Study of Liver Diseases (AASLD) and represents the position of the association.

A modified percutaneous transhepatic varices embolization with 2-octyl cyanoacrylate in the treatment of bleeding esophageal varices

BACKGROUND

To evaluate the effect of a modified percutaneous transhepatic variceal embolization (PTVE) with 2-octyl cyanoacrylate (2-OCA) on the prevention and treatment of esophageal variceal bleeding.

METHODS

Between March 2002 and December 2005, PTVE was attempted in 92 patients with esophageal varices, 74 patients with recent variceal bleeding, 18 patients with acute variceal bleeding. The 2-OCA was injected into the entire lower esophageal and periesophageal or paraesophageal varices, the cardial submucosal, and perforating vessels.

RESULTS

PTVE was successfully performed in 89 of 92 patients, providing a procedural success rate of 96.7%. According to the distribution of injected 2-OCA, 3 types of variceal embolization were defined, esophagogastric obliteration (n=42), gastric obliteration (n=34), and main left gastric vein obliteration (n=13). Acute variceal bleeding was immediately arrested in all 18 (100%) patients after the procedure. During the median follow-up period of 37 months, the total rebleeding rate was 19.1% (17/89), with the rate being higher in patients with main left gastric vein obliteration 46.1% (6/13) than in patients with esophagogastric obliteration 9.5% (4/42) or with gastric obliteration 20.6% (7/34, P<0.05). Total survival rate was 74.4%, with the rate being significantly higher in patients with esophagogastric obliteration and gastric obliteration than that in patients with left gastric vein obliteration demonstrated by Kaplan-Meier analysis (P<0.001, log-rank test). There was 1 patient with fatal bleeding at the puncture site after the PTVE procedure, and 1 patient with slight pulmonary embolism; there were no other major procedure-related complications.

CONCLUSIONS

The effect of PTVE with 2-OCA on esophageal varices is associated with the site and range of embolization. With the lower esophageal and periesophageal varices and/or the cardial submucosal and perforating vessels are sufficiently obliterated, PTVE with 2-OCA can improve long-term efficacy by preventing varices recurrence and rebleeding.

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.

Portal hypertension-related complications after acute portal vein thrombosis: impact of early anticoagulation

BACKGROUND & AIMS

Acute portal vein thrombosis (APVT) is a rare disorder that causes chronic portal hypertension if recanalization is not obtained. However, response to anticoagulation and long-term prognosis of APVT are not well-defined.

METHODS

Thirty-eight patients diagnosed with APVT between 1995 and 2003 from 5 Spanish referral hospitals, in whom cirrhosis and malignancy were specifically excluded, were included in this retrospective study. The response to anticoagulation therapy and development of portal hypertension-related complications during follow-up were evaluated.

RESULTS

Mean follow-up was 43 months (range, 6-112 months). Recanalization occurred in 12 of 27 patients receiving anticoagulation versus 0 of 11 patients who did not receive anticoagulation (P = .008). Rates of recanalization were influenced by the precocity of heparin administration and the number of underlying prothrombotic conditions. Follow-up upper endoscopy performed in 29 patients disclosed gastroesophageal varices in 16 (55%). Varices appeared as early as 1 month after APVT. However, in most patients varices were detected in successive endoscopies, mainly during the first year. Two-year actuarial probability of variceal bleeding was 12% and for ascites 16%. Five-year survival was 87%. Mortality was related to the APVT episode in 2 cases and to an underlying hematologic disorder in one.

CONCLUSIONS

Anticoagulation achieved recanalization in about 40% of patients. Most patients not achieving recanalization will develop gastroesophageal varices during follow-up. However, development of variceal bleeding and ascites is infrequent, and survival is satisfactory.

A modified percutaneous transhepatic variceal embolization with 2-octyl cyanoacrylate versus endoscopic ligation in esophageal variceal bleeding management: randomized controlled trial

BACKGROUND

Conventional percutaneous transhepatic varices embolization (PTVE) has rarely been used in recent years due to high rates of variceal recurrence and rebleeding. Herein we report a modified PTVE with 2-octyl cyanoacrylate (2-OCA) in which the whole lower esophageal and peri or para-esophageal varices, the submucosal varices, and the advertitial plexus of the cardia and fundus were sufficiently obliterated. We compared this PTVE with endoscopic band ligation (EVL) in the treatment of esophageal variceal bleeding.

METHODS

In this prospective randomized controlled trial, cirrhotic patients with acute or recent esophageal variceal bleeding were assigned randomly to PTVE (52 patients) or EVL (50 patients) groups. Upper gastrointestinal (UGI) rebleeding, esophageal variceal rebleeding, and survival were followed-up. Computerized tomography (CT) scanning and portal venography were used to observe 2-OCA distribution.

RESULTS

During the follow-up period (median 24 and 25 months in the PTVE and EVL groups, respectively) UGI rebleeding developed in eight patients in the PTVE group and 21 patients in EVL group (P = 0.004). Recurrent bleeding from esophageal varices occurred in three patients in the PTVE group and twelve in the EVL group (P = 0.012, relative risk 0.24, 95% confidence interval 0.05-0.74). Multivariate Cox analysis indicated that the treatment was the only factor predictive of rebleeding. A Kaplan-Meier curve showed there was no significant difference between survival in the two groups (P = 0.054).

CONCLUSIONS

With the whole lower esophageal and peri or para-esophageal varices, the submucosal varices, and the adventitial plexus of the cardia and fundus sufficiently obliterated by 2-OCA, this modified PTVE was more effective than EVL in the management of esophageal varices recurrence and rebleeding. Survival in these two groups was not significantly different, however.

Evaluation and management of end-stage liver disease in children

End-stage liver disease in children presents a challenging array of medical and psychosocial problems for the health care delivery team. Many of these problems are similar to those encountered by caregivers of adults with end-stage liver disease, such as the development of complications of cirrhosis, including ascites, spontaneous bacterial peritonitis, and esophageal variceal hemorrhage. However, the natural history of disease progression in children and their responses to medical therapy can differ significantly from that of their adult counterparts. Children with end-stage liver disease are especially vulnerable to nutritional compromise; if not effectively managed, this can seriously impact long-term outcomes and survival both before and after liver transplantation. Moreover, close attention must be given to vaccination status and the clinical setting at which health care is delivered to optimize outcomes and the delivery of high-quality pediatric health care. In this review, we address important components of the evaluation and management of children with chronic end-stage liver disease.

Partial splenectomy for portal hypertension in cystic fibrosis related liver disease

AIMS

To review the middle- and long-term effects of partial splenectomy (PS) on portal hypertension (PHT) and its complications in patients with cystic fibrosis (CF) related liver disease risky PHT.

METHOD

Over a 20 years period, 19 patients aged 7-23 years underwent partial PS for massive splenomegaly, hypersplenism, and/ or severe PHT.

RESULTS

In all but three cases, PHT and hypersplenism have improved for long periods. Noticeable improvement of hepatic tests occurred simultaneously. In all patients PS resolved abdominal discomfort. Fifteen patients are alive and a stabilization of the liver disease occurred with a follow-up of 1-20 years (mean 7.9). One patient died following respiratory insufficiency 10 years after PS although PHT was stable. Manifestations recurred in 2 patients 5 and 6 years after PS. In two patients, the course of the disease evolved to hepatic insufficiency without recurrence of PHT 3 and 8 years after PS. PS did not give the expected results in three cases only, in which PHT was not modified or reoccurred during the following year. No severe complication was observed. Early (three patients) or late (one patient) eventration required surgical procedure.

CONCLUSIONS

Our results show that PS is a reliable and well-tolerated technique. Therefore, it is a therapeutic option for the management of PHT in CF patients with a preserved liver function. It can prevent and significantly delay a liver transplantation and its constraints.

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.