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Prophylactic sclerotherapy in children with esophageal varices: long-term results of a controlled prospective
M E Gonçalves1, S R Cardoso, J G Maksoud
1Department of Surgery, Instituto da Criança-Hospital das Clínicas, University of São Paulo Medical School, Brazil.
Insights
Prophylactic sclerotherapy (PS) in children with portal hypertension effectively eliminates esophageal varices, reducing bleeding. However, it shifts bleeding sources to the stomach and does not improve survival rates.
Area of Science:
- Pediatric Gastroenterology
- Hepatology
- Endoscopic Interventions
Background:
- Prophylactic sclerotherapy (PS) for esophageal varices is established in adults, but data in children is limited and conflicting.
- No prior randomized controlled trials have evaluated PS in pediatric populations with portal hypertension.
Purpose of the Study:
- To prospectively assess the efficacy of PS in preventing the first hemorrhage from esophageal varices in children.
- To evaluate the impact of PS on the survival rate of pediatric patients with portal hypertension.
Main Methods:
- A prospective, randomized controlled trial involving 100 children with portal hypertension.
- Patients were randomized to receive PS (n=50) or serve as controls (n=50) with standard follow-up.
- Minimum follow-up was 18 months post-sclerotherapy cessation.
Main Results:
- PS eradicated esophageal varices in 94% of patients; 76% remained hemorrhage-free.
- Bleeding occurred in 24% before variceal obliteration; gastric varices and gastropathy caused bleeding in the PS group.
- Control group had higher rates of esophageal variceal bleeding (P<.05) but lower rates of gastric complications.
Conclusions:
- PS is effective in eradicating esophageal varices and reducing overall bleeding in children with portal hypertension.
- While PS reduces esophageal variceal bleeding, it can increase gastric bleeding and does not improve survival.
- PS is a safe procedure with few complications, though it may alter bleeding sources.
Background/Purpose:
Experience using endoscopic prophylactic sclerotherapy (PS) is restricted to adult patients and has led to conflicting results. There has not been a randomized, controlled study on the use of PS in children. The purpose of this study is to evaluate prospectively the value of PS to prevent the first hemorrhage from esophageal varices in children with portal hypertension and to assess the effect of PS on survival rate.
Methods:
In a controlled, prospective, computer-based randomized trial, the effectiveness of PS was analyzed in 100 consecutive children allocated to a group receiving sclerotherapy (n = 50) or to a control group (n = 50) subjected only to regular clinical and endoscopic examinations. Clinical characteristics in both groups were similar. The minimum follow-up period was at least 18 months after the cessation of the sessions of sclerotherapy.
Results:
After a median follow-up of 4.5 years, PS eliminated the esophageal varices in 47 of 50 (94%) patients but only 38 (76%) of them do not present upper digestive hemorrhage. Before complete obliteration of the varices, upper gastrointestinal bleeding occurred in 12 patients (24%). Six children (12%) had gastric varices, 3 of 6 of whom (50%) bled. Congestive hypertensive gastropathy was observed to occur in 8 (16%) patients, 4 of 8 of which (50%) had hemorrhagic episodes. Two patients bled from undetermined cause. In the control group, only 29 (58%) children remained free from esophageal variceal bleeding and 26 (52%) from any upper gastrointestinal bleeding (P<.05). During the follow-up period, the development of gastric varices was observed in 5 (10%) patients (P>.05) and of congestive hypertensive gastropathy in only 3 (6%) patients (P<.05), but none of them bled. PS does not improve survival rate.
Conclusions:
In children with cirrhotic and noncirrhotic portal hypertension, PS reduces the overall incidence of bleeding from esophageal varices that were eradicated in 94% of cases. The source of bleeding has been different in each group, being predominantly from esophageal varices in the control group and from the stomach in the prophylaxis group. When applied with appropriate technique, PS is a safe procedure with a low incidence of minor complications. PS does not change the incidence of gastric varices but increases the development of congestive hypertensive gastropathy. PS increases the risk of bleeding from the naturally formed gastric varices and from congestive hypertensive gastropathy. PS does not affect survival rate.