Use of beta-blockers for primary prophylaxis of variceal bleeding

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

BACKGROUND/PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

Endoscopic variceal band ligation (EVL) is the preferred method of treating variceal hemorrhage in adults. The need to reinsert the endoscope after reloading for each varix ligation has been a drawback. The Saeed multiband ligator allows ligation of multiple varices during a single insertion. The multibander has not been used previously in children.

METHODS

Twenty-eight consecutive children were referred to a pediatric liver unit because of esophageal variceal bleeding from 1998 to 2000. Endoscopic variceal band ligation was performed at initial endoscopy and repeated monthly until varices were obliterated or were too small to ligate.

RESULTS

Results are expressed as median (range). Age at EVL was 11 years (3 months to 16 years) and weight 30 kg (5.4-63 kg). Portal hypertension was caused by cirrhosis in 15 children. Endoscopic variceal band ligation was performed on 66 occasions with 4 bands applied per session. Ten children had active bleeding at initial endoscopy and all responded to EVL. Interval bleeding developed in 2 children before variceal ablation. Varices were obliterated in 26 of 28 patients after 2 sessions. During the 21-month follow-up (2 months to 3 years), six children have undergone elective liver transplantation and three have had mesoportal bypass procedures. Rebleeding developed in 2 of 26; 1 from recurrent esophageal varices that responded to repeat EVL and 1 from gastric varices. Following variceal ablation, 2-year actuarial variceal recurrence risk was 40%.

CONCLUSIONS

Endoscopic variceal ligation is highly effective in obliterating esophageal varices in children. The use of a multibander device for endoscopic variceal ligation is technically feasible and safe even in small children, and its use results in more rapid ablation of esophageal varices.