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

Noncirrhotic portal hypertension: current trends and future directions

PURPOSE OF REVIEW

Noncirrhotic portal hypertension (NCPH) comprises a diverse group of vascular liver disorders characterized by elevated portal pressure without cirrhosis. Due to overlapping clinical features, distinguishing NCPH from cirrhosis and porto-sinusoidal vascular disorder (PSVD) remains challenging. This review explores recent advancements in diagnosis, differentiation, and evolving treatment strategies.

RECENT FINDINGS

NCPH is characterized by preserved liver function and near-normal hepatic venous pressure gradients (HVPG). It shares risk factors with PSVD, including infections, drugs, toxins, and prothrombotic conditions. Diagnostic advancements, such as liver stiffness measurement (LSM) and splenic stiffness measurement (SSM), offer noninvasive differentiation from cirrhosis, while liver biopsy remains crucial for confirming PSVD and noncirrhotic portal fibrosis (NCPF). Imaging is reliable for diagnosing extrahepatic portal vein obstruction (EHPVO). Transjugular intrahepatic portosystemic shunts (TIPS) for refractory variceal bleeding or ascites, achieving rebleeding control in 72-80% of cases. Surgical shunts and splenectomy remain essential for uncontrolled bleeding and portal biliopathy, demonstrating excellent variceal control (93-95%).

SUMMARY

NCPH requires a high index of suspicion for diagnosis. Differentiation from cirrhosis and PSVD relies on clinical, histological, and hemodynamic assessments. Management focuses on endoscopic, interventional, and surgical strategies tailored to disease severity. Future research should standardize diagnostic criteria, explore targeted therapies, and refine prognostic tools to improve outcomes.

Utility of endoscopy in paediatric gastroenterology and hepatology-Review and updates

Paediatric endoscopy has been an integral part of the diagnostic evaluation and management of gastroenterology and hepatology diseases in children. This area of clinical medicine has made meteoric advancements since it was first introduced conserving it's traditional roles of gastroscopy and colonoscopy but broadening significantly it's clinical utility and diagnostic accuracy with new and emerging technology. This article aims to explore and review the current utility and emerging applications of diagnostic and therapeutic endoscopy for the practicing paediatric gastroenterologist and hepatologist.

Idiopathic non-cirrhotic portal hypertension: A case report

RATIONALE

Idiopathic noncirrhotic portal hypertension (INCPH) is a rare liver disorder with elevated portal pressure without cirrhosis, making diagnosis challenging. This case report presents a 46-year-old Chinese male with INCPH, highlighting the crucial role of liver biopsy.

PATIENT CONCERNS

A 46-year-old male presented with persistent fatigue that lasted for 2 months and significantly worsened over the last 3 days. The patient described his fatigue as a profound lack of energy that persisted throughout the day, which progressively impaired his ability to perform daily activities and maintain his usual work responsibilities. He reported feeling exhausted even after light physical exertion, such as walking or standing for short periods. The severity of the fatigue also led to frequent short rests during the day, and he experienced difficulty concentrating and carrying out routine tasks. In addition, he noted a loss of appetite and mild discomfort in the upper abdomen. Given his previous history of abnormal liver function tests and a liver biopsy showing mild chronic liver damage, the patient was initially diagnosed with cirrhosis at a local hospital. This initial diagnosis caused significant emotional distress, as the patient experienced a state of panic and anxiety over the implications of having a progressive liver disease. The psychological burden was evident in his reported difficulty sleeping and persistent worry about his health and future.

DIAGNOSES

Initial imaging suggested portal hypertension and cirrhosis, but a liver biopsy ruled out cirrhotic changes, confirming INCPH by excluding other causes such as chronic hepatitis.

INTERVENTIONS

The patient received symptomatic treatment (acid suppression, gastric and liver protection) and underwent a liver biopsy. Histological analysis confirmed INCPH, ruling out cirrhosis.

OUTCOMES

After the definitive diagnosis, the patient's anxiety lessened. Fatigue and weakness improved with ongoing symptomatic treatment, and psychological support enhanced his overall well-being. His follow-up plan includes regular liver function monitoring, imaging for portal pressure changes, and potential anticoagulation therapy for thrombosis risks.

LESSONS

This case highlights the diagnostic difficulty of INCPH and underscores the importance of liver biopsy. Further research is needed to develop specific diagnostic tools and treatments for INCPH.

The effectiveness of endoscopic sclerotherapy in the treatment of esophageal varices in children with prehepatic portal hypertension

AIM

This study aims to evaluate the outcomes of endoscopic sclerotherapy (EST) in the treatment of esophagogastric varices in cases of extrahepatic portal hypertension (EHPH) secondary to portal vein thrombosis.

MATERIALS AND METHODS

Records of cases that underwent endoscopic sclerotherapy for esophagogastric varices between 1990 and 2022 in our clinic were retrospectively reviewed. The age, gender, symptomatology, etiology, clinical, laboratory, and radiological data of the patients, as well as treatment outcomes, were evaluated. Results were compared based on age groups, time periods, and etiological factors. The classification of the Japanese Portal Hypertension Research Society was used for variceal assessment. The absence of bleeding or bleeding not requiring transfusion within one year was considered a positive outcome.

RESULTS

Of the 126 cases that underwent endoscopy with a diagnosis of EHPH, 41 had varices at the F1-F2 level and were not subjected to sclerotherapy. In 21 cases, due to advanced varices, gastropathy findings, frequent bleeding episodes, and hypersplenism, surgical indication was established after the first endoscopy. The remaining 64 cases were included in the study. Positive outcomes were achieved in 44 cases with an average of 4.1 sessions. Desired outcomes were not achieved in 20 cases, and surgical procedures were performed. When the results were evaluated based on the periods 1990-2000, 2001-2010, and 2011-2022, the success rates were 60%, 44%, and 88.2%, respectively. Statistically significant more favorable results were obtained in the last decade.

CONCLUSION

EST is a safe and effective minimally invasive method for the elective treatment of esophagocardial varices in children with EHPH. More effective results have been achieved with increased experience and advancements in imaging technology.

Endoscopic variceal ligation combined with sclerotherapy for management of gastroesophageal variceal bleeding in pediatric patients: a single-center retrospective study

Objectives

Portal hypertension (PH) frequently gives rise to severe and life-threatening complications, including hemorrhage accompanied by the rupture of esophageal and gastric varices. In contrast to the guidelines for the management of PH in adults, the optimal endoscopic management of variceal bleeding for secondary prophylaxis in children remains unclear. The present study evaluated the efficacy and safety of endoscopic variceal ligation (EVL) and endoscopic sclerotherapy (EST) to control gastroesophageal variceal bleeding in children.

Methods

This retrospective study included children with gastroesophageal variceal bleeding who underwent EST or EVL at Xinhua Hospital, Shanghai Jiaotong University School of Medicine, between February 2013 and March 2020. Short-term hemostasis rate and long-term rebleeding rate were evaluated. Adverse events related to the procedures, such as esophageal ulcer, esophageal stricture, abnormal embolization, pneumonia and perforation, were also recorded.

Results

EVL (n = 8) and EST (n = 13) were performed successfully in all pediatric patients diagnosed with moderate to severe esophageal varices concurrent with gastric varices. Hemostasis was achieved during episodes of upper gastrointestinal bleeding. The mean volume of each single aliquot of cyanoacrylate injected was 0.3 ± 0.1 ml (range: 0.1-0.5 ml). Varices were eradicated in six (75%) of the eight patients who underwent EVL after a median 2 (range: 1-4) procedures and a median time of 3.40 months (range: 1.10-13.33 months). Eleven (52.4%) of the 21 patients developed rebleeding events, with the mean duration of hemostasis being 11.1 ± 11.6 months (range 1.0-39.2 months). No treatment-related complications, for example, distal embolism, occurred except for abdominal pain in one patient (4.8%).

Conclusions

EST, alone or in combination with EVL, is an effective and safe method of managing gastroesophageal variceal hemorrhage in children undergoing secondary prophylaxis.

Paediatric gastrointestinal endoscopy in the Asian-Pacific region: Recent advances in diagnostic and therapeutic techniques

There has been a rapid expansion in the knowledge of paediatric gastroenterology over the recent decade, with a fast-growing repertoire of diagnostic techniques and management strategies for a wide spectrum of childhood gastrointestinal (GI) diseases. Paediatric GI endoscopy is a core competency every paediatric gastroenterologist should possess, and represents one of the most common procedures performed in children for both diagnostic and therapeutic purposes. Yet there remains a dearth of literature on the utility and outcomes of paediatric GI endoscopy in the Asia-Pacific region. Data on the diagnostic value of paediatric GI endoscopy would be an important aspect of discussion, with the emergence of inflammatory bowel disease (IBD) and eosinophilic GI disease as increasingly common endoscopic diagnoses. Time-based trends in paediatric GI endoscopy do point towards more IBD and gastroesophageal reflux disease-related complications being diagnosed, with a declining incidence of GI bleeding. However, the real-world diagnostic value of endoscopy in Asia must be contextualised to the region-specific prevalence of paediatric GI diseases. Helicobacter pylori infection, particularly that of multidrug-resistant strains, remains a highly prevalent problem in specific regions. Paediatric functional GI disorders still account for the majority of childhood GI complaints in most centres, hence the diagnostic yield of endoscopy should be critically evaluated in the absence of alarm symptoms. GI therapeutic endoscopy is also occasionally required for children with ingested foreign bodies, intestinal polyposis or oesophageal strictures requiring dilation. Endoscopic haemostasis is a potentially life-saving skill in cases of massive GI bleeding typically from varices or peptic ulcers. Advanced endoscopic techniques such as capsule endoscopy and balloon-assisted enteroscopy have found traction, particularly in East Asian centres, as invaluable diagnostic and therapeutic tools in the management of IBD, obscure GI bleeding and intestinal polyposis. State of the art endoscopic diagnostics and therapeutics, including the use of artificial intelligence-aided endoscopy algorithms, real-time confocal laser endomicroscopy and peroral endoscopic myotomy, are expected to gain more utility in paediatrics. As paediatric gastroenterology matures as a subspecialty in Asia, it is essential current paediatric endoscopists and future trainees adhere to minimum practice standards, and keep abreast of the evolving trends in the diagnostic and therapeutic value of endoscopy. This review discusses the available published literature on the utility of paediatric GI endoscopy in Asia Pacific, with the relevant clinical outcomes.

PREDICTIVE FACTORS OF MORBIDITY ASSOCIATED WITH ESOPHAGEAL VARICEAL BLEEDING IN CHILDREN WITH PORTAL HYPERTENSION

•Most data on the natural history of portal hypertension come from studies in adults. •The morbidity rate of upper gastrointestinal bleeding in children with portal hypertension tend to be underestimated. •This study showed the relevance of morbidity rates after variceal hemorrhage in pediatric patients, especially those with cirrhosis. •Patients with hemodynamic instability requiring blood transfusion or expansion on admission are at increased risk of complications secondary to upper gastrointestinal bleeding and should be closely monitored. Background - Most data on the natural history of portal hypertension come from studies in adults. The morbidity rate of upper gastrointestinal bleeding (UGIB) in children with portal hypertension has not been systematically characterized. Objective - To describe the morbidity and mortality of UGIB in pediatric patients with portal hypertension and identify predictive factors for the occurrence of its main complications. Methods - This retrospective study included pediatric patients with cirrhotic portal hypertension or with extrahepatic portal vein obstruction (EHPVO). Mortality and UGIB complications within a period of up to 6 weeks of the bleeding were investigated. To determine the predictive factors of morbidity, a multivariate analysis was performed using logistic regression; all results were considered significant at P<0.05. Results - A total of 86 patients (51.2% with EHPVO and 48.8% with cirrhosis) had 174 bleeding events. Ascites was the most common complication (43.1% of all cases), being more prevalent in patients with cirrhosis (P<0.001). Cirrhosis was a predictor of the occurrence of any morbidity (OR 20.3). The need for blood transfusion was predictor of at least one complication (OR 5.8), ascites (OR 7.2) and infections (OR 3.8) in the general group and at least one complication (OR 11.3) and ascites (OR 5.8) in cirrhotic patients. The need for expansion was a predictor of any morbidity (OR 4.6) and infections (OR 3.9) in the general group, in addition to being predictor of infection in cirrhotic patients (OR 5.4). There were no deaths from UGIB in the six weeks post-bleeding. Conclusion - The study showed the relevance of morbidity after UGIB in pediatric patients with portal hypertension, especially in those with cirrhosis. The patients with hemodynamic instability requiring blood transfusion or expansion on admission are at increased risk of complications related to upper gastrointestinal bleeding and should be closely monitored.

Consensus on the management of complications of cirrhosis of the liver in pediatrics

The Asociación Mexicana de Hepatología A.C. carried out the Consensus on the Management of Complications of Cirrhosis of the Liver in Pediatrics to provide physicians with useful information for treating said complications. A group of pediatric gastroenterologists and experts in nutrition, nephrology, and infectious diseases participated and reviewed the medical literature. The Delphi method was applied to obtain the level of agreement on the statements that were formulated. The statements were sent to the participants to be analyzed and voted upon, after which they were discussed in virtual sessions, and the final versions were produced. The aim of the consensus results was to issue indications for the management of pediatric patients with liver cirrhosis, to prevent or control complications.

Interventional endoscopy for abdominal transplant patients

Interventional endoscopy can play a significant role in the care and management of children pre-and post- abdominal solid organ transplantation. Such procedures primarily include endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and balloon-assisted enteroscopy (BAE), though additional interventions are available using standard endoscopes (gastroscopes, colonoscopes) for therapeutics purposes such as endoscopic hemostasis. The availability of pediatric practitioners with the advanced training to effectively and safely perform these procedures are most often limited to large tertiary care pediatric centers. These centers possess the necessary resources and ancillary staff to provide the comprehensive multi-disciplinary care needed for these complex patients. In this review, we discuss the importance of interventional endoscopy in caring for transplant patients, during their clinical course preceding the potential need for solid organ transplantation and inclusion of a discussion related to endoscopic post-surgical complication management. Given the highly important role of interventional endoscopy in patients with recurrent and chronic pancreatitis, we also include a discussion related to this complex disease process leading up to those patients that may need pancreas surgery including total pancreatectomy with islet autotransplantation (TPIAT).

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.

Pediatric non-cirrhotic portal hypertension: Endoscopic outcome and perspectives from developing nations

Non-cirrhotic portal hypertension (NCPH) forms an important subset of portal hypertension in children. Variceal bleed and splenomegaly are their predominant presentation. Laboratory features show cytopenias (hypersplenism) and preserved hepatic synthetic functions. Repeated sessions of endoscopic variceal ligation or endoscopic sclerotherapy eradicate esophageal varices in almost all cases. After variceal eradication, there is an increased risk of other complications like secondary gastric varices, cholangiopathy, colopathy, growth failure, especially in extra-hepatic portal vein obstruction (EHPVO). Massive splenomegaly-related pain and early satiety cause poor quality of life (QoL). Meso-Rex bypass is the definitive therapy when the procedure is anatomically feasible in EHPVO. Other portosystemic shunt surgeries with splenectomy are indicated when patients present late and spleen-related issues predominate. Shunt surgeries prevent rebleed, improve growth and QoL. Non-cirrhotic portal fibrosis (NCPF) is a less common cause of portal hypertension in children in developing nations. Presentation in the second decade, massive splenomegaly and patent portal vein are discriminating features of NCPF. Shunt surgery is required in severe cases when endotherapy is insufficient for the varices. Congenital hepatic fibrosis (CHF) presents with firm palpable liver and splenomegaly. Ductal plate malformation forms the histological hallmark of CHF. CHF is commonly associated with Caroli’s disease, renal cysts, and syndromes associated with neurological defects. Isolated CHF has a favourable prognosis requiring endotherapy. Liver transplantation is required when there is decompensation or recurrent cholangitis, especially in Caroli’s syndrome. Combined liver-kidney transplantation is indicated when both liver and renal issues are present.

Endoscopic prophylaxis and factors associated with bleeding in children with extrahepatic portal vein obstruction

OBJECTIVES

This study aimed to evaluate factors associated with upper digestive hemorrhage and primary and secondary endoscopic prophylaxis outcomes in children with extrahepatic portal vein obstruction.

METHODS

This observational and prospective study included 72 children with extrahepatic portal vein obstruction who were followed from 2005 to 2017. Risk factors associated with upper digestive hemorrhage and the results of primary and secondary prophylaxis of these patients were evaluated.

RESULTS

Fifty patients (69.4%) had one or more episodes of bleeding during follow-up, with a median age at first hemorrhage of 4.81 years. The multivariate analysis showed that medium- to large-caliber esophageal varices were associated with an 18-fold risk of upper digestive hemorrhage (95% CI: 4.33-74.76; p < 0.0001). Primary prophylaxis was administered to 14 patients, with eradication in 85.7%; however, 14.3% of these patients had hemorrhages during the follow-up period and 41.7% had a relapse of varices. Secondary prophylaxis was administered to 41 patients. Esophageal varices were eradicated in 90.2% of patients. There were relapse and re-bleeding of esophageal varices in 45.9% and 34.1% of the children, respectively.

CONCLUSION

Primary and secondary endoscopic prophylaxes showed high rates of esophageal varix eradication, but with significant relapses. Eradication of esophageal varices cannot definitively prevent recurrent upper digestive hemorrhage, since bleeding from alternate sites can occur. Medium- and large-caliber esophageal varices were associated with upper digestive hemorrhage in patients with extrahepatic portal vein obstruction. To the best of the authors' knowledge, this study is the first to evaluate bleeding risk factors in children with extrahepatic portal vein obstruction.

Pediatric Cirrhotic Variceal Bleed Precipitating Diabetic Ketoacidosis

Cirrhosis and its associated complications such, as variceal bleeding, are rare in children, carrying significant morbidity and mortality. Leading causes of cirrhosis in the pediatric population include infection, neoplasm, and metabolic and genetic disorders, which is in contrast to the adult population. Acute gastrointestinal bleeding, as seen with variceal bleeding, has been previously associated with diabetic ketoacidosis through a multifactorial relationship. The case was complicated by hypovolemic shock whose resuscitation and subsequent transfusion was associated with cardiac overload. We highlight the need for balanced, judicious resuscitation in these individuals as well as the need for heightened awareness of coexisting pathologies such as diabetic ketoacidosis.

Long-term Outcomes and Health Perceptions in Pediatric-onset Portal Hypertension Complicated by Varices

OBJECTIVES

Outcomes of pediatric-onset portal hypertension are poorly defined. We aimed to assess population-based long-term outcomes of pediatric-onset portal hypertension complicated by varices.

METHODS

All children with esophageal varices (n = 126) were identified from 14,144 single nationwide referral center endoscopy reports during 1987 to 2013, and followed up through national health care and death registers. A questionnaire was sent to survivors (n = 94) of whom 65 (69%) responded.

RESULTS

Nineteen underlying disorders included biliary atresia (35%), extrahepatic portal vein obstruction (35%), autosomal recessive polycystic kidney disease (7%), and other disorders (23%). During median follow-up of 15.2 (range 0.5-43.1) years patients underwent median 9 (1-74) upper gastrointestinal endoscopies. Esophageal varices were first observed at a median age of 4.0 (0.3-18.2) years, 112 (89%) patients underwent median 6 (1-56) sclerotherapy/banding sessions, and 61 (48%) experienced median 2 (range 1-20) variceal bleeding episodes. Forty-eight surgical shunt procedures were performed to 41 (36%) patients and 38% underwent liver transplantation. Portal hypertensive biliopathy was diagnosed in 4 patients. Hepatopulmonary syndrome necessitated liver transplantation in 2 patients, hepatic encephalopathy in 2, and hepatorenal syndrome in 1. No patient died of variceal bleeding. Patient-reported perception of health on a scale of 1 to 10 was 9 (range 4-10), and 86% reported no current symptoms attributable to esophageal varices.

CONCLUSIONS

Pediatric-onset portal hypertension is a heterogeneous disease with significant long-term morbidity, requiring multimodal approach with considerable resources and continuation of follow-up in adulthood. Although mortality to variceal bleeding was avoided, bleeding episodes recurred also in adulthood, while patient-reported health of long-term survivors was encouraging.

Prevalence, nature, and predictors of colonic changes in children with extrahepatic portal vein obstruction

BACKGROUND AND AIMS

The medical literature on colonic changes in children with extrahepatic portal venous obstruction (EHPVO) is limited. We evaluated EHPVO children for prevalence, nature, and relation of colonic changes with disease duration, extent of splenoportal axis (SPA) thrombosis, portal hypertensive gastropathy (PHG), and esophageal varices (EVs). The correlation between histologic and endoscopic changes was studied.

METHODS

Subjects were evaluated by colonoscopy with ileoscopy and biopsy sampling, clinico-laboratory profiles, and SPA imaging. Colonic changes were classified as varices (rectal/colonic) and portal hypertensive colopathy (PHC; colitis-like or vascular lesions). Morphometric analysis of colonic biopsy specimens was performed.

RESULTS

Fifty-four children (median age, 12 years [range, 8-15]; hematochezia in 9 [16.6%]) were evaluated. Rectal and colonic varices were seen in 51 (94%) and 2 (3.7%) cases, respectively. Seventy-five percent of patients had PHC, and colitis-like lesions were more common than vascular lesions (36/40 vs 23/40; P = .001). Colopathy changes were pancolonic in 52.5%, left-sided in 42.5%, and right-sided in 5% of cases. Sixteen percent of patients (8/49) had ileal changes. Children with PHC had PHG more often (90% vs 57%; P = .01), more endotherapy sessions (mean 6 [range, 4-8] vs 2 [range, 1-4]; P = .03), and large EVs less often (12.5% vs 43%; P = .02) than those without colopathy. The extent of SPA thrombosis was similar in patients with and without PHC. The number of capillaries per crypt was higher in EHPVO than in control subjects. Morphometric changes had no correlation with endoscopy.

CONCLUSIONS

Most EHPVO children had colonic changes, and 16% had ileopathy. "Colitis-like" changes and left-side involvement were more common. Patients with PHG and eradicated EVs had a higher risk of PHC.

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.

Noncirrhotic Portal Hypertension: Current and Emerging Perspectives

Idiopathic portal hypertension (IPH) and extrahepatic portal venous obstruction (EHPVO) are prototype noncirrhotic causes of portal hypertension (PHT), characterized by normal hepatic venous pressure gradient, variceal bleeds, and moderate to massive splenomegaly with preserved liver synthetic functions. Infections, toxins, and immunologic, prothrombotic and genetic disorders are possible causes in IPH, whereas prothrombotic and local factors around the portal vein lead to EHPVO. Growth failure, portal biliopathy, and minimal hepatic encephalopathy are long-term concerns in EHPVO. Surgical shunts and transjugular intrahepatic portosystemic shunt resolve the complications secondary to PHT. Meso-Rex shunt is now the standard-of-care surgery in children with EHPVO.

Portal Hypertension of a Delayed Onset Following Liver Abscesses in a 12-Month-Old Infant: A Case Report and Review of the Literature

We report a 12-month-old female infant who had a history of neonatal sepsis with liver micro-abscesses that resolved with intravenous antibiotics during neonatal period. During her neonatal admission period, no umbilical vein catheter was inserted. Also, she did not undergo any abdominal surgeries or had a postnatal history of necrotizing enterocolitis. However, the child developed upper gastrointestinal bleeding in form of hematemesis and melena secondary to esophageal varices at the age of 12 months with an extra-hepatic portal vein obstruction with cavernous transformation and portal hypertension subsequently. The child underwent a successful endoscopic injection sclerotherapy. She is now 20-month-old and has portal hypertension but otherwise asymptomatic. We are proposing the possibility of a delayed-onset portal hypertension as a complication of liver abscess and neonatal sepsis.

Novel insights into the assessment of risk of upper gastrointestinal bleeding in decompensated cirrhotic children

OBJECTIVES

Cirrhotic children wait-listed for liver transplant are prone to bleeding from gastrointestinal varices. Grade 2-3 esophageal varices, red signs, and gastric varices are well-known risk factors. However, the involvement of hemostatic factors remains controversial because of the rebalanced state of coagulation during cirrhosis.

METHODS

Children suffering from decompensated cirrhosis were prospectively included while being on waitlist. Portal hypertension was assessed by ultrasound and endoscopy. Coagulopathy was evaluated through conventional tests, thromboelastometry, and platelet function testing. The included children were followed up until liver transplantation, and all bleeding episodes were recorded. Children with or without bleeding were compared according to clinical, radiological, endoscopic, and biological parameters. In addition, validation of a predictive model for risk of variceal bleeding comprising of grade 2-3 esophageal varices, red spots, and fibrinogen level <150 mg/dL was applied on this cohort.

RESULTS

Of 20 enrolled children, 6 had upper gastrointestinal bleeding. Significant differences were observed in fibrinogen level, adenosine diphosphate, and thrombin-dependent platelet aggregation. The model used to compute the upper gastrointestinal bleeding risk had an estimated predictive performance of 81.0%. Platelet aggregation analysis addition improved the estimated predictive performance up to 89.0%.

CONCLUSIONS

We demonstrated an association between hemostatic factors and the upper gastrointestinal bleeding risk. A low fibrinogen level and platelet aggregation dysfunction may predict the risk of bleeding in children with decompensated cirrhosis. A predictive model is available to assess the upper gastrointestinal bleeding risk but needs further investigations. Clinicaltrials.gov number: NCT03244332.

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.

Primary Prophylaxis for Gastrointestinal Bleeding in Children With Biliary Atresia and Portal Hypertension Candidates for Liver Transplantation: A Single-Center Experience

BACKGROUND

Cirrhosis for biliary atresia (BA) is associated with risk of gastrointestinal bleeding (GB) from gastroesophageal varices due to portal hypertension. Primary prophylaxis of GB is controversial in children who are candidates for liver transplantation (LT). The aim of the study was to define the management of gastroesophageal varices and to identify the benefit of primary prophylaxis for GB in BA children waiting for LT.

METHODS

A retrospective single-center study including all BA children listed for LT in 2008-2016. Clinical, endoscopical, and biochemical data were analyzed.

RESULTS

Of 82 children, 50 (61%) did not receive primary prophylaxis and did not present any episode of bleeding, 16 (19.5%) underwent primary prophylaxis, and 16 (19.5%) presented spontaneous GB and received secondary prophylaxis. Children without primary prophylaxis and GB were younger than patients with primary prophylaxis and those with GB (7.7 years [range, 4.1-37.9 years] vs 11.2 years [range, 5.1-43 years]; P = .03 vs 10.7 years [range, 6.9-39.9 years], respectively; P = .004). Seventy-five percent of GB occurred in children older than 8 months. Fifteen (93.8%) children with GB presented esophageal varices (grade III = 10 [62.5%]) and 10 (62.5%) required endoscopic treatments, consisting mainly of sclerotherapy. Median time to LT was similar for children with or without bleeding (2 months [range, 0-17.7 months] vs 2.2 months [0-17.9 months], respectively; P = .89). After 45.5 months (range, 13.7-105.5 months) of follow-up, the overall patient survival was 97.6%. At the intention-to-treat analysis, the survival rate was 100% for patients without bleeding episode and 87.5% for children with GB (P = .16).

CONCLUSIONS

Despite the risk of GB being not clinically predictable in children with BA waiting for LT, our experience suggests that primary prophylaxis of GB might be unnecessary in children younger than 6 months, while it should be considered in older children. Thus, the occurrence of GB does not delay the timing of transplantation.

Pediatric Endoscopic Procedure Complications

PURPOSE OF REVIEW

This review summarizes the current body of research, define high-risk patients and endoscopic processes, and outline evidence-based countermeasures aimed at minimizing the incidence of complications during endoscopy in children.

RECENT FINDINGS

Significant complications of endoscopy requiring emergency department or inpatient admission in otherwise healthy children are unusual, but more common with therapeutic procedures; risk from procedures increases incrementally with preoperative coexisting conditions. Duodenal hematoma is predominantly a pediatric endoscopic complication and is more likely in hematology-oncology patients. Air embolism is a well-defined endoscopic retrograde cholangiopancreatography (ERCP) complication in adults and is likely to increase in children with increased performance of pediatric ERCP. Increased physician expertise is the most often proposed countermeasure, especially in the context of endoscopy complications in the higher-risk patient and procedure. Endoscopy in children remains a very safe group of procedures, although a more detailed understanding of risk factors and ideal training and practice organization is lacking.

Bleeding risk of variceal band ligation in extrahepatic portal vein obstruction is not increased by oral anticoagulation

BACKGROUND AND OBJECTIVES

Noncirrhotic nontumoral extrahepatic portal vein obstruction (EHPVO) is the second leading cause of portal hypertension (PHT) and is mainly related to prothrombotic disorders. Patients with EHPVO often require prolonged oral anticoagulation therapy (OAT) together with variceal band ligation (VBL) to prevent thrombosis recurrence and PHT-related bleeding, respectively. The benefit-risk balance of VBL in this context remains unknown. We aimed to assess upper gastrointestinal bleeding (UGB) risk and variceal eradication efficacy in EHPVO patients undergoing a VBL program without stopping OAT.

PATIENTS AND METHODS

All patients with EHPVO treated (group A) or not (group B) with OAT and undergoing the VBL program were included between 2001 and 2010 in two tertiary French liver centers. We compared the incidence, source, and severity of UGB and variceal eradication efficacy. All EHPVO patients were then matched 1 : 1 with compensated cirrhotic patients with PHT not receiving OAT (group C) to compare UGB incidence and VBL efficacy.

RESULTS

Forty-three EHPVO patients (30 with and 13 without OAT) and 43 cirrhotic patients were included for a total of 471 VBL sessions. The incidence of UGB was similar between group A (nine episodes/121 sessions) and group B (6/130), and tended to be higher in EHPVO patients (group A and B) than in cirrhotic patients (2/220). There was no difference between groups when considering bleeding source or severity and variceal eradication efficacy (84%).

CONCLUSION

VBL can be performed safely and efficiently without stopping anticoagulation therapy in EHPVO patients.

Idiopathic portal hypertension and extrahepatic portal venous obstruction

BACKGROUND

Idiopathic portal hypertension (IPH) and extrahepatic portal venous obstruction (EHPVO) are non-cirrhotic vascular causes of portal hypertension (PHT). Variceal bleed and splenomegaly are the commonest presentations.

AIM

The present review is intended to provide the existing literature on etiopathogenesis, clinical profile, diagnosis, natural history and management of IPH and EHPVO.

RESULTS

IPH and EHPVO are both characterized by normal hepatic venous pressure gradient, moderate to massive splenomegaly with preserved liver synthetic functions. While the level of block in IPH is presinusoidal, in EHPVO it is at prehepatic level. Infections, autoimmunity, drugs, immunodeficiency and prothrombotic states are possible etiological agents in IPH. Contrastingly in EHPVO, prothrombotic disorders and local factors around the portal vein are the incriminating factors. Diagnosis is often clinical, supported by simple radiological tools. Natural history is defined by episodes of variceal bleed and symptoms related to enlarged spleen. Growth failure, portal biliopathy and minimal hepatic encephalopathy are additional concerns in EHPVO. Long-term survival is reasonably good with endoscopic surveillance; however, parenchymal extinction leading to decompensation is seen in a minority of patients in both the disorders. Surgical shunts revert the complications secondary to PHT. Meso-Rex shunt has become the standard surgery in children with EHPVO.

CONCLUSION

This review gives a detailed summary of these two vascular conditions of liver-IPH and EHPVO. Further research is needed to understand the pathogenesis and natural history of these disorders.

Portal hypertension and its management in children

Portal hypertension (PHT), defined as raised intravascular pressure in the portal system, is a complication of chronic liver disease or liver vascular occlusion. Advances in our ability to diagnose and monitor the condition but also predict the risk of gastrointestinal bleeding have enabled us to optimise the management of children with PHT either at a surveillance or at a postbleeding stage. A consensus among paediatric centres in the classification of varices can be beneficial in streamlining future paediatric studies. New invasive (endoscopic and surgical procedures) and non-invasive (pharmacotherapy) techniques are currently used enabling clinicians to reduce mortality and morbidity in children with PHT.

Successful treatment of repeated hematemesis secondary to postsclerotherapy esophageal ulcer in a cirrhotic patient: A case report

Esophageal variceal bleeding is a common lethal complication of cirrhosis. Endoscopic injection sclerotherapy (EIS) is one of the major endoscopic approaches for treating esophageal variceal bleeding. However, complications may occur after EIS, which mainly include retrosternal discomfort/pain, dysphagia, re-bleeding, esophageal ulcer, esophageal strictures, and esophageal perforation, etc. In this article, we reported a 36-year-old male who developed esophageal ulcer related bleeding after EIS. Currently, there is no consensus on the treatment strategy for esophageal ulcer-related bleeding after EIS. In the present case, the following treatment strategy may be effective for ulcer related bleeding. The first step is to inhibit gastric acid secretion and reduce portal pressure by intravenous infusion of esomeprazole and somatostatin, respectively. The second is local hemostasis by oral norepinephrine and lyophilizing thrombin powder. The third is to protect digestive tract mucosa by oral Kangfuxin Ye and aluminum phosphate.

Extrahepatic Portal Venous Obstruction: What Should be the Mainstay of Treatment?

The two cornerstones of management for Extrahepatic portal vein obstruction (EHPVO) are endotherapy and surgery [Porto-systemic shunts (PSS)/Mesorex bypass (MRB)]. Endotherapy is the mainstay of treatment for acute variceal bleed control and has also been used extensively for secondary prophylaxis till variceal eradication is achieved. However, long-term follow-up beyond endoscopic eradication of esophageal varices (EEEV) indicates that there are numerous delayed bleed and non bleed sequelae of EHPVO, which merit surgery as a definitive procedure to decompress the hypertensive portal venous system. While endotherapy obliterates natural porto-systemic collaterals in the gastroesophageal region, persistently raised portal pressures manifest as an increase in secondary isolated gastric varices, ectopic varices, portal hypertensive vasculopathy, issues related to massive splenomegaly, portal biliopathy, growth retardation and hence impaired quality of life (QOL). An ideal management strategy should address both bleed and non-bleed consequences of EHPVO and translate into a near normal QOL. Further, MRB has opened up new dimensions to the management philosophy of EHPVO. This review article critically evaluates the role of surgery and endotherapy based on available literature and authors' own experience.Surgery and endotherapy are complementary. However, with increasing duration of follow-up post EEEV, it is evident that there is resurgence in the role of surgery (PSS/MRB) as a single one time definitive procedure for alleviating all bleed and delayed non bleed sequelae of EHPVO.Surgery for EHPVO (PSS/MRB) should not be allowed to become a dying art and future generations of surgeons should continue to receive training in this specialized area of surgery.

Survey on Clinical Practice of Primary Prophylaxis in Portal Hypertension in Children

Primary prophylaxis in portal hypertension in children is controversial, because there are few studies documenting its efficacy on the risk of bleeding. Twenty-eight centres out of the 38 we contacted returned a completed questionnaire about their clinical practices. More than 75% of the centres use endoscopy to screen patients diagnosed with portal cavernoma, biliary atresia, cystic fibrosis, and other fibrotic chronic liver diseases with suspected portal hypertension. In cases of grade 2 varices with red marks and grade 3 varices >90% of centres perform sclerotherapy or endoscopic variceal ligation. Noncardioselective beta-blockers were used by approximately 20% of centres. In conclusion, despite the absence of scientific recommendations there is a tacit consensus concerning the need to screen children with clinical signs of portal hypertension, and to provide primary prophylaxis in cases of endoscopic patterns of high-risk varices.

Working Subgroup for Clinical Practice Guideline for Aberrant Portal Hemodynamics. Diagnosis and treatment guidelines for aberrant portal hemodynamics: The Aberrant Portal Hemodynamics Study Group supported by the Ministry of Health, Labor and Welfare of Japan

Idiopathic portal hypertension (IPH), causing aberrant portal hemodynamics, is a disease with an as yet unidentified cause and no established treatment protocol. The Japanese research group on IPH in Japan was set up in 1975 by the Ministry of Health, Labor and Welfare. Extrahepatic portal obstruction and Budd-Chiari syndrome (BCS) have since been added to the group's research subjects. The aims of the research group are to accurately evaluate the current status of the three diseases in Japan, elucidate their etiology and pathogenesis, and develop new treatments. Due to the long-term efforts of the Japanese research group, aberrant portal hemodynamics has been investigated in a variety of aspects, from epidemiological and pathological studies to molecular biology analyses. As a result, it has been shown that there are abnormal genes in the liver, specific for IPH. In addition, pathological findings of BCS were internationally compared and the difference in findings between Japan and Europe (or North America) has been clarified. Furthermore, it was found that complication rates of hepatocellular carcinoma in BCS were higher in Japan. Based on the research, "Diagnosis and treatment of aberrant portal hemodynamics (2001)", including diagnostic criteria for aberrant portal hemodynamics, was published in 2001. In 2013, it was revised to "Diagnosis and treatment guidelines for aberrant portal hemodynamics (2013)" after the incorporation of diagnosis and treatment in accordance with its current status.

Therapeutic Endoscopy for the Control of Nonvariceal Upper Gastrointestinal Bleeding in Children: A Case Series

OBJECTIVES

Gastrointestinal bleeding is one of the most common indications for urgent endoscopy in the pediatric setting. The majority of these procedures are performed for control of variceal bleeding, with few performed for nonvariceal upper gastrointestinal (NVUGI) bleeding. The data on therapeutic endoscopy for NVUGI are sparse. The aims of our study were to review our experience with NVUGI bleeding, describe technical aspects and outcomes of therapeutic endoscopy, and determine gastroenterology fellows' training opportunities according to the national training guidelines.

METHODS

We performed a retrospective review of endoscopy database (Endoworks, Olympus Inc, Center Valley, PA) from January 2009 to December 2014. The search used the following keywords: bleeding, hematemesis, melena, injection, epinephrine, cautery, clip, and argon plasma coagulation. The collected data included demographics, description of bleeding lesion and medical/endoscopic therapy, rate of rebleeding, relevant laboratories, physical examination, and need for transfusion and surgery. The study was approved by the institutional review board.

RESULTS

During the study period 12,737 upper endoscopies (esophagogastroduodenoscopies) were performed. A total of 15 patients underwent 17 esophagogastroduodenoscopies that required therapeutic intervention to control bleeding (1:750 procedures). The mean ± standard deviation (median) age of patients who required endoscopic intervention was 11.6 ± 6.0 years (14.0 years). Seven out of 17 patients received dual therapy to control the bleeding lesions. All but 3 patients received medical therapy with intravenous proton pump inhibitor, and 3 received octreotide infusions. Six of the patients experienced rebleeding (40%), with 4 out of 6 initially only receiving single modality therapy. Two of these patients eventually required surgical intervention to control bleeding and both patients presented with bleeding duodenal ulcers. There were no cases of aspiration, perforation, or deaths. There were a total of 24 fellows trained in our program during the study period. Less than 1 therapeutic endoscopy per fellow for NVUGI bleeding was performed.

CONCLUSIONS

NVUGI bleeding requiring therapeutic endoscopic intervention is rare in pediatrics. A high rate (40%) of rebleeding was noted with a large proportion (66%) of patients receiving single modality therapy. Two patients required surgical intervention to control bleeding and both presented with bleeding duodenal ulcers. An insufficient number of therapeutic procedures is available for adequate fellow training requiring supplemental simulator and hands-on animal model, or adult endoscopy unit training.

King's Variceal Prediction Score: A Novel Noninvasive Marker of Portal Hypertension in Pediatric Chronic Liver Disease

BACKGROUND AND AIMS

Variceal haemorrhage can be a life-threatening complication of chronic liver disease in children. There is limited evidence about the optimal prophylactic management and selection criteria of children who will benefit from upper gastrointestinal endoscopy.

METHODS

Children presenting in our centre with suspected portal hypertension or gastrointestinal bleeding and undergoing their first oesophagogastroduodenoscopy between 2005 and 2012 were included. Clinical, biochemical, and radiological data were collected. A separate validation cohort from May 2013 to October 2014 was obtained.

RESULTS

Data on 124 treatment-naïve patients were collected; 50% had biliary atresia. Thirty-five (28%) children presented with gastrointestinal bleeding and overall 79 (64%) had clinically significant (grade II-III) varices. Clinical prediction rule, aspartate aminotransferase-platelet ratio index, and varices prediction rule had at optimal cut-off sensitivity and specificity of 76% and 59%, 60% and 55%, and 80% and 59%, respectively. Logistic regression yielded a new prediction rule of (3 × albumin ([g/dL]) -  (2 - equivalent adult spleen size [cm]). This King's variceal prediction score had a favourable areas under the curve of 0.772 (0.677-0.867) compared to clinical prediction rule 0.732 (0.632-0.832). At the optimal cut-off of 76 this yielded a sensitivity and specificity of 72% and 73% and a positive and negative predictive value of 82% and 60%, respectively. In the validation cohort areas under the curve was 0.818 (0.654-0.995) with sensitivity and specificity of 78% and 73%, respectively.

CONCLUSIONS

Our new prediction score may be a useful tool in the selection of children with clinically significant varices eligible for a screening endoscopy.

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.

Portal hypertension in children: High-risk varices, primary prophylaxis and consequences of bleeding

BACKGROUND & AIMS

Primary prophylaxis of bleeding is debated for children with portal hypertension because of the limited number of studies on its safety and efficacy, the lack of a known endoscopic pattern carrying a high-risk of bleeding for all causes, and the assumption that the mortality of a first bleed is low. We report our experience with these issues.

METHODS

From 1989 to 2014, we managed 1300 children with portal hypertension. Endoscopic features were recorded; high-risk varices were defined as: grade 3 esophageal varices, grade 2 varices with red wale markings, or gastric varices. Two hundred forty-six children bled spontaneously and 182 underwent primary prophylaxis. The results of primary prophylaxis were reviewed as well as bleed-free survival, overall survival and life-threatening complications of bleeding.

RESULTS

High-risk varices were found in 96% of children who bled spontaneously and in 11% of children who did not bleed without primary prophylaxis (p<0.001), regardless of the cause of portal hypertension. Life-threatening complications of bleeding were recorded in 19% of children with cirrhosis and high-risk varices who bled spontaneously. Ten-year probabilities of bleed-free survival after primary prophylaxis in children with high-risk varices were 96% and 72% for non-cirrhotic causes and cirrhosis respectively. Ten-year probabilities of overall survival after primary prophylaxis were 100% and 93% in children with non-cirrhotic causes and cirrhosis respectively.

CONCLUSION

In children with portal hypertension, bleeding is linked to the high-risk endoscopic pattern reported here. Primary prophylaxis of bleeding based on this pattern is fairly effective and safe.

LAY SUMMARY

In children with liver disease, the risk of bleeding from varices in the esophagus is linked to their large size, the presence of congestion on their surface and their expansion into the stomach but not to the child's age nor to the cause of portal hypertension. Prevention of the first bleed in children with high-risk varices can be achieved by surgery or endoscopic treatment, and decreases mortality and morbidity.

Biliary atresia: Indications and timing of liver transplantation and optimization of pretransplant care

Biliary atresia (BA) is a progressive, fibro-obliterative disorder of the intrahepatic and extrahepatic bile ducts in infancy. The majority of affected children will eventually develop end-stage liver disease and require liver transplantation (LT). Indications for LT in BA include failed Kasai portoenterostomy, significant and recalcitrant malnutrition, recurrent cholangitis, and the progressive manifestations of portal hypertension. Extrahepatic complications of this disease, such as hepatopulmonary syndrome and portopulmonary hypertension, are also indications for LT. Optimal pretransplant management of these potentially life-threatening complications and maximizing nutrition and growth require the expertise of a multidisciplinary team with experience caring for BA. The timing of transplant for BA requires careful consideration of the potential risk of transplant versus the survival benefit at any given stage of disease. Children with BA often experience long wait times for transplant unless exception points are granted to reflect severity of disease. Family preparedness for this arduous process is therefore critical. Liver Transplantation 23:96-109 2017 AASLD.

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.

Reasons and risk factors for irregular-interval endoscopic variceal sclerotherapy in patients with esophageal variceal bleeding

OBJECTIVE

Endoscopic variceal sclerotherapy (EVS) is usually carried out at weekly intervals in patients with esophageal variceal bleeding (EVB). However, some patients receive sclerotherapy at irregular intervals. In this study we aimed to elucidate the reasons and risk factors for irregular-interval sclerotherapy in patients with EVB, and to evaluate the safety and efficacy of interrupted irregular intervals in these patients.

METHODS

Medical records of patients who were admitted to the Chinese PLA General Hospital from December 2013 to June 2015 for EVS were retrospectively analyzed. EVS sessions were scheduled to be repeated at regular weekly intervals. However, some of these patients received at least one treatment session at irregular intervals (mainly <7 days). This irregular-interval group was further divided into those whose treatment was rescheduled for emergency and elective reasons.

RESULTS

Irregular treatment intervals were mainly caused by early rebleeding, initial emergency treatment, and holidays. However, there were no differences in the rates of complication and variceal eradication between patients treated at weekly and irregular intervals. Multivariate logistic regression analysis identified ascites (P = 0.0009), variceal erosion (P = 0.0003), and maximum injected volume of sclerosing agent per session (P = 0.0008) to be associated with emergency irregular-interval treatment. Only age differed between the elective irregular-treatment and weekly treatment groups.

CONCLUSIONS

Early rebleeding, initial emergency treatment, and treatment over holidays may necessitate irregular sclerotherapy intervals in patients with EVB. Moreover, ascites, variceal erosion, and maximum injected volume of sclerosing agent per session are risk factors for emergency sclerotherapy, whereas elective adjustments to treatment schedules as a result of holidays do not affect the outcomes of patients undergoing EVS for EVB.

Endoscopic management of bleeding gastric varices with N-butyl, 2-cyanoacrylate glue injection in children with non-cirrhotic portal hypertension

Background and study aims: In view of the paucity of literature, we carried out this audit to evaluate the safety and efficacy of N- butyl, 2-cynoacrylate glue injection therapy in secondary prophylaxis of gastric varices in children. Patients and methods: Consecutive children (≤ 18 years) with non-cirrhotic portal hypertension who presented with bleeding from gastric varices and who had undergone cyanoacrylate glue injection therapy were included. They were evaluated for safety, efficacy and complications. Their long-term outcomes and follow-up were recorded. Results: Over 11 years, 28 children with median age 13 (range, 8 to 18) years (68 % boys), underwent cyanoacrylate glue injection for bleeding gastric varices. In 25 (89 %) cases, extrahepatic portal venous obstruction was the etiology and isolated gastric varices were the source of the bleeding. Primary and secondary gastric variceal bleeding was seen in 11 (39 %) and 17 (61 %) children, respectively. A total 36 sessions with median volume of 2 (range, 1 - 5) mL of glue injections were required (2 sessions in 8 children). Hemostasis was achieved in all and 57 % had gastric variceal obliteration. Two children had early (< 1 month) rebleeding and 2 children had late rebleeding. One child had gastric ulcer. Over a median follow-up of 24 (8 - 98) months, 14 children underwent surgery (12 porto-systemic shunt), 2 were lost to follow-up, 1 died and there was no recurrence of bleeding in the remaining 11. Conclusions: Cyanoacrylate glue injection is highly effective mode of secondary prophylaxis of bleeding gastric varices in children with non-cirrhotic portal hypertension. Rebleeding occurred in 14 % but treatment-related complications were uncommon. However, a large controlled clinical trial is required to confirm our findings.

[Use of Hemospray® in post-sclerotherapy bleeding]

BACKGROUND

Hemospray® is a new device for endoscopic hemostasis used for non-variceal gastrointestinal bleeding. It enables hemostasis and platelet activation by increasing the concentration of clotting factors and forming a mechanical barrier on the wall of a bleeding vessel creating a mechanical plug at the site of bleeding. Within the main indications for use are: injuries with difficult endoscopic access, massive gastrointestinal bleeding, multiple bleeding sites, modification of the anatomy by previous endoscopic therapy, presence of coagulopathy, difficulty in having direct visualization or when it is impossible to have contact with the bleeding lesion. However, its use in children has not been approved yet by the FDA. There is a case report of an 11-month-old patient successfully treated with Hemospray® for non-variceal gastrointestinal bleeding.

CLINICAL CASE

We report the case of a 2-year-old female with acute liver failure and primary biliary cirrhosis with portal hypertension and bleeding after sclerotherapy. We analyzed the case to support new therapies for massive bleeding control in post-sclerotherapy esophageal ulcers.

CONCLUSIONS

The application showed to be safe without side effects. Using Hemospray® is an effective alternative in controlling gastrointestinal bleeding.

Endoscopic Evaluation in Children With End-Stage Liver Disease-Associated Portal Hypertension Awaiting Liver Transplant

OBJECTIVES

Routine oesophago-gastro-duodenoscopy (OGD) pre-liver transplantation (LT) for evaluation and management of gastrointestinal (GI) pathology, in particular GI varices secondary to portal hypertension, is common practice in adult LT programmes. There is no universal consensus for this practice in children. We report our endoscopic experience in children with end-stage liver disease (ESLD) pre-LT.

METHODS

Retrospective audit of LT database and review of OGD findings of patients who had undergone endoscopy preceding LT.

RESULTS

Of 69 patients with ESLD, 50 (72.4%) had pre-LT OGD, 37 of which were done electively, whereas the remaining 13 were event driven. Forty-eight (96%) patients who underwent OGD had abnormalities, in which 38 (76%) patients had varices and 23 (46%) had portal hypertensive gastropathy. Eleven (22%) patients required therapeutic intervention at initial OGD either with endoscopic variceal band ligation or endoscopic sclerotherapy. Compared with the group who underwent elective OGDs, the group who had event-driven OGDs had a significantly higher requirement for endoscopic intervention (P < 0.0001), occurrence of rebleeding (P < 0.029) and requirement for repeat OGDs (P = 0.014). There was no significant difference in terms of patient (P = 0.2746) or graft survival (P = 0.3192) between the 2 groups.

CONCLUSIONS

The role of pre-LT OGDs in patients with ESLD associated with portal hypertension is possibly limited to control of bleeding during episodes of GI bleed, where the aim would be to stabilize the patient until eventual LT. Multicentre prospective studies are required to provide more evidence on the use of routine endoscopy for pre-LT assessment in children.

Primary prophylaxis of variceal bleeding in children and the role of MesoRex Bypass: Summary of the Baveno VI Pediatric Satellite Symposium

Approaches to the management of portal hypertension and variceal hemorrhage in pediatrics remain controversial, in large part because they are not well informed by rigorous clinical studies. Fundamental biological and clinical differences preclude automatic application of approaches used for adults to children. On April 11-12, 2015, experts in the field convened at the first Baveno Pediatric Satellite Meeting to discuss and explore current available evidence regarding indications for MesoRex bypass (MRB) in extrahepatic portal vein obstruction and the role of primary prophylaxis of variceal hemorrhage in children. Consensus was reached regarding MRB. The vast majority of children with extrahepatic portal vein obstruction will experience complications that can be prevented by successful MRB surgery. Therefore, children with extrahepatic portal vein obstruction should be offered MRB for primary and secondary prophylaxis of variceal bleeding and other complications, if appropriate surgical expertise is available, if preoperative and intraoperative evaluation demonstrates favorable anatomy, and if appropriate multidisciplinary care is available for postoperative evaluation and management of shunt thrombosis or stenosis. In contrast, consensus was not achieved regarding primary prophylaxis of varices. Although variceal hemorrhage is a concerning complication of portal hypertension in children, the first bleed appears to be only rarely fatal and the associated morbidity has not been well characterized.

CONCLUSION

There are few pediatric data to indicate the efficacy and safety of pharmacologic or endoscopic therapies as primary prophylaxis or that prevention of a sentinel variceal bleed will ultimately improve survival; therefore, no recommendation for primary prophylaxis with endoscopic variceal ligation, sclerotherapy, or nonspecific beta-blockade in children was proposed.

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.

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.

Successful emergency combined therapy with partial splenic arterial embolization and endoscopic injection therapy against a bleeding duodenal varix in a child

There is no consensus guidelines for treating duodenal variceal bleeding, which is a rare and life-threatening complication of portal hypertension. Here we report an exceedingly unusual case in a 9-year-old boy who had developed left-sided portal hypertension after surgical treatment for pancreatoblastoma followed by a duodenal variceal bleeding with massive melena, severe anemia (hemoglobin 4.5 g/dL) and hypovolemic shock. Emergency partial splenic arterial embolization (PSE) provided a reduction of variceal bleeding and improved blood pressure. Endoscopic injection sclerotherapy (EIS) was subsequently performed and stopped the duodenal variceal bleeding without the complication of portal vein thrombosis caused by injected sclerosant under hepatopetal flow. Our case demonstrates that emergency combined therapy with PSE and EIS can be considered as the therapeutic option for the management of left-sided portal hypertension-induced ectopic variceal bleedings in order to avoid the complication of portal embolization by EIS and provide effective hematostasis.

Extrahepatic portal vein obstruction in Egyptian children

BACKGROUND AND AIM

Extrahepatic portal vein obstruction (EHPVO) is an important cause of portal hypertension in children. The aim of this study was to describe the clinical presentation, possible risk factors, upper gastrointestinal endoscopic findings, and treatment modalities of children with EHPVO.

METHODS

After ethical approval of our study protocol by our institution review board, we analyzed available data from medical records of patients with EHPVO presenting to the Pediatric Hepatology Unit, Cairo University Pediatric Hospital, Egypt, for a period of 15 years from January 1996 to December 2010.

RESULTS

The study included 169 patients. Their ages at presentation ranged from 1 month to 12 years (median 2.5 years, interquartile range 5); 101 were boys. Hematemesis was a presenting symptom in 58%, splenomegaly was present in 87%, esophageal varices were present in 94%, and fundal varices were present in 23%. Possible risk factors, in the form of umbilical catheterization, umbilical sepsis, and exchange transfusion, were elicited in 18%. Propranolol was associated with reduction in bleeding episodes (P < 0.001), but was associated with increased chest symptoms (P < 0.01). Both injection sclerotherapy and band ligation were effective in the management of bleeding varices and for primary and secondary prophylaxis; however, injection sclerotherapy was associated with the development of secondary gastric varices (P = 0.03).

CONCLUSIONS

This large study of children with EHPVO demonstrates the efficacy of propranolol in the reduction of gastrointestinal bleeding in children with EHPVO. Both injection sclerotherapy and band ligation were effective in the management of esophageal varices, although the former was associated with the development of secondary gastric varices. Randomized clinical trials to choose the best modalities for the management of portal hypertension in children are still lacking.