Noninvasive markers for esophageal varices in children with cirrhosis

Endoscopic Primary Prophylaxis to Prevent Bleeding in Children with Esophageal Varices: A Systematic Review and Meta-Analysis

Purpose

This systematic review and meta-analysis aimed to compare endoscopy as primary versus secondary prophylaxis to prevent future bleeding in children with esophageal varices.

Methods

A systematic literature search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method was conducted using the Scopus, PubMed, and Cochrane databases for relevant studies on the outcome of rebleeding events after endoscopy in primary prophylaxis compared to that in secondary prophylaxis. The following keywords were used: esophageal varices, children, endoscopy, primary prophylaxis and bleeding. The quality of eligible articles was assessed using the Newcastle-Ottawa Scale and statistically analyzed using RevMan 5.4 software.

Results

A total of 174 children were included from four eligible articles. All four studies were considered of high-quality based on the Newcastle-Ottawa Quality Assessment Scale. Patients who received primary prophylaxis had 79% lower odds of bleeding than those who received secondary prophylaxis (odds ratio, 0.21; 95% confidence interval [CI], 0.07-0.66; I2=0%, p=0.008). Patients in the primary prophylaxis group underwent fewer endoscopic procedures to eradicate varices than those in the secondary prophylaxis group, with a mean difference of 1.73 (95% CI, 0.91-2.56; I2=62%, p<0.0001).

Conclusion

Children with high-risk varices who underwent primary prophylaxis were less likely to experience future bleeding episodes and required fewer endoscopic procedures to eradicate the varices than children who underwent secondary prophylaxis.

Understanding the use of oral rehydration therapy: A narrative review from clinical practice to main recommendations

Background and Aims

Fluid loss due to diarrhea remains a significant cause of mortality among children under the age of 5.

Methods

Oral rehydration therapy (ORT) is a first-line therapeutic measure to compensate the volume loss due to diarrhea and vomiting among gastroenteritis patients. Despite adequate knowledge, the practice of ORT is limited, particularly in developing countries.

Results

Several recommendations are provided regarding the use of ORT to treat hypovolemia, however, the information regarding its adequate usage is restricted within the healthcare centers and professionals.

Conclusion

This review highlights the importance of providing recommendations regarding the use of ORT. We also discuss the barriers and alternatives that might limit its use.

Use of biochemical parameters for non-invasive screening of oesophageal varices in comparison to elastography-based approach in patients with compensated advanced chronic liver disease

Introduction

Oesophageal varices are routinely diagnosed by esophagogastroduodenoscopy (EGD), and their bleeding has high mortality. We aimed to evaluate diagnostic performance of biochemical tests in comparison to elastography-based approaches, as non-invasive alternatives to EGD, for ruling-out high risk oesophageal varices (HRV).

Material and methods

Retrospective analysis of patients (N = 861) who underwent liver stiffness measurement (LSM) by transient elastography (TE) in a single centre over 5-year period, with available results of EGD (within 3 months from LSM). Only patients with suspicion of compensated advanced chronic liver disease (cACLD) defined by LSM ≥ 10 kPa were included comprising the final cohort of 73 subjects. Original and expanded Baveno VI criteria (B6C), controlled attenuation parameter (CAP), platelet count (PLT), aspartate aminotransferase to PLT ratio index (APRI), Fibrosis-4 index (FIB4), model for end stage liver disease (MELD) score were evaluated against the results of EGD that served as the reference method.

Results

Analysed patients had median age 62 years, 59/73 (0.81) were males, 54/73 (0.74) had alcoholic/non-alcoholic fatty liver disease, and 21/73 (0.29) had HRV. In multivariate logistic regression analysis only LSM and PLT were independently associated with HRV. The best performing tests for ruling-out HRV (% of spared EGD; % of missed HRV) were respectively: LSM < 20 kPa (53.4%; 0%), B6C (38%; 0%), Expanded B6C (47.9%; 4.8%); PLT > 214x10⁹/L (21.9%; 0%); FIB4 ≤ 1.8 (21.4%; 0%), APRI ≤ 0.34 (12.3%; 0%). CAP, MELD = 6 alone or combined with PLT > 150(x10⁹/L) did not show acceptable performance.

Conclusion

The best performing biochemical tests for ruling-out HRV in our cohort of patients were PLT and FIB-4, but they were still outperformed by elastography-based approaches.

Small varices in chronic liver diseases

PURPOSE OF REVIEW

Gastroesophageal varices are common complications of chronic liver diseases (CLDs) and portal hypertension. Small varices have the risk of progressing to larger varices, causing bleeding or even death. Thus, early detection and appropriate management of small varices are necessary. The purpose of this review is to summarize the advance in the recent 5years about diagnosing and managing the small varices in CLDs.

RECENT FINDINGS

The diagnosing methods of small varices in recent studies include improved endoscopic examinations, such as capsule endoscopy, and many noninvasive methods, including blood tests, ultrasound, computed tomography and magnetic resonance. For the management of small varices, though it is controversial, prevention using nonselective beta-blockers is still an essential part.

SUMMARY

In this review, we summarize the classification of varices, the invasive and noninvasive diagnostic methods, their performances, and the emerging progression in the management of small varices in the recent 5 years. We hope that this review provides relevant information to understand better and appropriately manage small varices.

Primary endoscopic variceal ligation reduced acute variceal bleeding events but not long-term mortality in pediatric-onset portal hypertension

BACKGROUND/PURPOSE

Esophageal variceal bleeding (EVB) is a medical emergency in patients with portal hypertension (PHT). However, studies on the long-term outcomes of prophylactic endoscopic variceal ligation (EVL) in pediatric-onset PHT are lacking.

METHODS

Between 1999 and 2020, patients who received EVL in the Electronic Report System of the Pediatric Endoscopy Unit were included in this retrospective study. EVL was classified as primary prophylaxis when it was performed for esophageal varices (EVs) without previous bleeding. If it was implemented in acute EVB, the subsequent EVL was classified as secondary prophylaxis.

RESULTS

Fifty-eight patients aged 10 months to 33 years with 31 males were included. Thirty-eight patients were classified as primary prophylaxis group, and twenty, secondary prophylaxis group. The primary prophylaxis group experienced fewer 5-year EVB events than the secondary prophylaxis group (cumulative risk: 14.4% versus 32.4%). Still, it didn't significantly affect overall survival and biliary atresia transplant-free survival. Long-term mortality was significantly associated with higher serum direct bilirubin levels (≥0.55 mg/dL) and lower albumin levels (≤2.54 mg/dL) at the first EVL. Aspartate aminotransferase-to-platelet ratio index (APRI) with a cut-off value of 1.24 helped to predict EV presence at the initial esophagogastroduodenoscopy (EGD) (AUROC = 0.762, sensitivity 75.0%, and specificity 66.7%).

CONCLUSION

Primary prophylactic EVL, despite reducing acute EVB, may not change overall survival and biliary atresia transplant-free survival. APRI > 1.24 may predict EV presence at the first EGD and help to schedule a surveillance EGD. Higher direct bilirubin and lower albumin levels at the first EVL may relate to long-term mortality.