Pediatr Gastroenterol Hepatol Nutr.  2013 Mar;16(1):1-9. 10.5223/pghn.2013.16.1.1.

Recent Trends in the Endoscopic Management of Variceal Bleeding in Children

• Kim SJ
• Kim KM

• KMID: 1428800
• DOI: http://doi.org/10.5223/pghn.2013.16.1.1

Abstract

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.

Keyword

Esophageal and gastric varices; Prevention & Control; Therapeutics; Child

MeSH Terms

Adult
Biliary Atresia
Child
Esophageal and Gastric Varices
Hemorrhage
Humans
Ligation
Portal Vein

Reference

1. Sokal EM, Van Hoorebeeck N, Van Obbergh L, Otte JB, Buts JP. Upper gastro-intestinal tract bleeding in cirrhotic children candidates for liver transplantation. Eur J Pediatr. 1992. 151:326–328.

2. Stringer MD, Howard ER, Mowat AP. Endoscopic sclerotherapy in the management of esophageal varices in 61 children with biliary atresia. J Pediatr Surg. 1989. 24:438–442.

3. Sharara AI, Rockey DC. Gastroesophageal variceal hemorrhage. N Engl J Med. 2001. 345:669–681.

4. Okuda K, Matsutani S. Portal-systemic collaterals: anatomy and clinical implications. 1991. Tokyo: Springer-Verlag.

5. Stringer MD, Howard ER. Longterm outcome after injection sclerotherapy for oesophageal varices in children with extrahepatic portal hypertension. Gut. 1994. 35:257–259.

6. Kim SY, Seo JK. Esophageal varix in children: endoscopic evaluation and clinical characteristics. J Korean Pediatr Soc. 1993. 36:1691–1700.

7. de Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2010. 53:762–768.

8. Maksoud JG, Goncalves ME, Porta G, Miura I, Velhote MC. The endoscopic and surgical management of portal hypertension in children: analysis of 123 cases. J Pediatr Surg. 1991. 26:178–181.

9. Howard ER, Stringer MD, Mowat AP. Assessment of injection sclerotherapy in the management of 152 children with oesophageal varices. Br J Surg. 1988. 75:404–408.

10. Yachha SK, Sharma BC, Kumar M, Khanduri A. Endoscopic sclerotherapy for esophageal varices in children with extrahepatic portal venous obstruction: a follow-up study. J Pediatr Gastroenterol Nutr. 1997. 24:49–52.

11. Sarin SK, Misra SP, Singal AK, Thorat V, Broor SL. Endoscopic sclerotherapy for varices in children. J Pediatr Gastroenterol Nutr. 1988. 7:662–666.

12. Kim KM, Seo JK. Evaluation of the underlying etiology and long-term prognostic factors in neonatal cholestasis. Korean J Pediatr Gastroenterol Nutr. 1999. 2:46–58.

13. Duché M, Ducot B, Tournay E, Fabre M, Cohen J, Jacquemin E, et al. Prognostic value of endoscopy in children with biliary atresia at risk for early development of varices and bleeding. Gastroenterology. 2010. 139:1952–1960.

14. Shneider B, Emre S, Groszmann R, Karani J, McKiernan P, Sarin S, et al. Expert pediatric opinion on the Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. Pediatr Transplant. 2006. 10:893–907.

15. Shneider BL, Bosch J, de Franchis R, Emre SH, Groszmann RJ, Ling SC, et al. 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. Pediatr Transplant. 2012. 16:426–437.

16. Garcia-Tsao G, Groszmann RJ, Fisher RL, Conn HO, Atterbury CE, Glickman M. Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology. 1985. 5:419–424.

17. Miraglia R, Luca A, Maruzzelli L, Spada M, Riva S, Caruso S, et al. Measurement of hepatic vein pressure gradient in children with chronic liver diseases. J Hepatol. 2010. 53:624–629.

18. Gana JC, Turner D, Roberts EA, Ling SC. Derivation of a clinical prediction rule for the noninvasive diagnosis of varices in children. J Pediatr Gastroenterol Nutr. 2010. 50:188–193.

19. Alves JG, Ulisses Montenegro FM. Portal hypertension due to schistosomiasis. Indian Pediatr. 2001. 38:1416–1418.

20. Runyon BA, Van Epps DE. Diuresis of cirrhotic ascites increases its opsonic activity and may help prevent spontaneous bacterial peritonitis. Hepatology. 1986. 6:396–399.

21. Gonçalves ME, Cardoso SR, Maksoud JG. Prophylactic sclerotherapy in children with esophageal varices: long-term results of a controlled prospective randomized trial. J Pediatr Surg. 2000. 35:401–405.

22. Oh SH, Song SM, Kim KM. Esophageal varices in children: Risk factors for variceal bleeding. 2011. In : Annual Meeting of Korean Pediatric Society; Seoul: 231(A).

23. Molleston JP. Variceal bleeding in children. J Pediatr Gastroenterol Nutr. 2003. 37:538–545.

24. Shashidhar H, Langhans N, Grand RJ. Propranolol in prevention of portal hypertensive hemorrhage in children: a pilot study. J Pediatr Gastroenterol Nutr. 1999. 29:12–17.

25. Ozsoylu S, Kocak N, Demir H, Yuce A, Gurakan F, Ozen H. Propranolol for primary and secondary prophylaxis of variceal bleeding in children with cirrhosis. Turk J Pediatr. 2000. 42:31–33.

26. Itha S, Yachha SK. Endoscopic outcome beyond esophageal variceal eradication in children with extrahepatic portal venous obstruction. J Pediatr Gastroenterol Nutr. 2006. 42:196–200.

27. Duché M, Habès D, Roulleau P, Haas V, Jacquemin E, Bernard O. Prophylactic endoscopic sclerotherapy of large esophagogastric varices in infants with biliary atresia. Gastrointest Endosc. 2008. 67:732–737.

28. Maksoud-Filho JG, Goncalves ME, Cardoso SR, Gibelli NE, Tannuri U. Long-term follow-up of children with extrahepatic portal vein obstruction: impact of an endoscopic sclerotherapy program on bleeding episodes, hepatic function, hypersplenism, and mortality. J Pediatr Surg. 2009. 44:1877–1883.

29. Sasaki T, Hasegawa T, Nakajima K, Tanano H, Wasa M, Fukui Y, et al. Endoscopic variceal ligation in the management of gastroesophageal varices in postoperative biliary atresia. J Pediatr Surg. 1998. 33:1628–1632.

30. Avgerinos A, Armonis A, Stefanidis G, Mathou N, Vlachogiannakos J, Kougioumtzian A, et al. Sustained rise of portal pressure after sclerotherapy, but not band ligation, in acute variceal bleeding in cirrhosis. Hepatology. 2004. 39:1623–1630.

31. Villanueva C, Piqueras M, Aracil C, Gomez C, Lopez-Balaguer JM, Gonzalez B, et al. A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol. 2006. 45:560–567.

32. Sarin SK. Long-term follow-up of gastric variceal sclerotherapy: an eleven-year experience. Gastrointest Endosc. 1997. 46:8–14.

33. Tan PC, Hou MC, Lin HC, Liu TT, Lee FY, Chang FY, et al. A randomized trial of endoscopic treatment of acute gastric variceal hemorrhage: N-butyl-2-cyanoacrylate injection versus band ligation. Hepatology. 2006. 43:690–697.

34. Kim SJ, Kim R, Song SM, Oh SH, Rhee KW, Kim KM. Histoacryl (N-Butyl-2-Cyanoacrylate) injection for treatment of gastric varices in children: a single center experience. 2012. In : World Congress of Pediatric Gastroenterology, Hepatology and Nutrition; 266–267(A).

35. Tuggle DW, Bennett KG, Scott J, Tunell WP. Intravenous vasopressin and gastrointestinal hemorrhage in children. J Pediatr Surg. 1988. 23:627–629.

36. Siafakas C, Fox VL, Nurko S. Use of octreotide for the treatment of severe gastrointestinal bleeding in children. J Pediatr Gastroenterol Nutr. 1998. 26:356–359.

37. Lam JC, Aters S, Tobias JD. Initial experience with octreotide in the pediatric population. Am J Ther. 2001. 8:409–415.

38. Moon JH, Tae MH, Beck NS. A study of endoscopic variceal ligation of under 6-year-old aged children with esophageal varices. J Korean Pediatr Soc. 2000. 43:1241–1247.

39. McKiernan PJ, Beath SV, Davison SM. A prospective study of endoscopic esophageal variceal ligation using a multiband ligator. J Pediatr Gastroenterol Nutr. 2002. 34:207–211.

40. Zargar SA, Javid G, Khan BA, Yattoo GN, Shah AH, Gulzar GM, et al. Endoscopic ligation compared with sclerotherapy for bleeding esophageal varices in children with extrahepatic portal venous obstruction. Hepatology. 2002. 36:666–672.

41. Lo GH, Lai KH, Cheng JS, Chen MH, Huang HC, Hsu PI, et al. Endoscopic variceal ligation plus nadolol and sucralfate compared with ligation alone for the prevention of variceal rebleeding: a prospective, randomized trial. Hepatology. 2000. 32:461–465.

42. Poddar U, Bhatnagar S, Yachha SK. Endoscopic band ligation followed by sclerotherapy: Is it superior to sclerotherapy in children with extrahepatic portal venous obstruction? J Gastroenterol Hepatol. 2011. 26:255–259.

43. Poddar U, Thapa BR, Singh K. Band ligation plus sclerotherapy versus sclerotherapy alone in children with extrahepatic portal venous obstruction. J Clin Gastroenterol. 2005. 39:626–629.

44. Superina R, Bambini DA, Lokar J, Rigsby C, Whitington PF. Correction of extrahepatic portal vein thrombosis by the mesenteric to left portal vein bypass. Ann Surg. 2006. 243:515–521.

45. Hill ID, Bowie MD. Endoscopic sclerotherapy for control of bleeding varices in children. Am J Gastroenterol. 1991. 86:472–476.

46. Karrer FM, Holland RM, Allshouse MJ, Lilly JR. Portal vein thrombosis: treatment of variceal hemorrhage by endoscopic variceal ligation. J Pediatr Surg. 1994. 29:1149–1151.

47. Price MR, Sartorelli KH, Karrer FM, Narkewicz MR, Sokol RJ, Lilly JR. Management of esophageal varices in children by endoscopic variceal ligation. J Pediatr Surg. 1996. 31:1056–1059.

48. Fox VL, Carr-Locke DL, Connors PJ, Leichtner AM. Endoscopic ligation of esophageal varices in children. J Pediatr Gastroenterol Nutr. 1995. 20:202–208.

49. Hall RJ, Lilly JR, Stiegmann GV. Endoscopic esophageal varix ligation: technique and preliminary results in children. J Pediatr Surg. 1988. 23:1222–1223.

50. Poza Cordon J, Froilan Torres C, Burgos Garcia A, Gea Rodriguez F, Suárez de Parga JM. Endoscopic management of esophageal varices. World J Gastrointest Endosc. 2012. 4:312–322.

51. Westaby D. Emergency and elective endoscopic therapy for variceal haemorrhage. Baillieres Clin Gastroenterol. 1992. 6:465–480.

52. Seewald S, Ang TL, Imazu H, Naga M, Omar S, Groth S, et al. A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos). Gastrointest Endosc. 2008. 68:447–454.