Endoscopic prophylaxis and factors associated with bleeding in children with extrahepatic portal vein obstruction
Ana Paula Pereira de Oliveira1, Alexandre Rodrigues Ferreira1, Eleonora Druve Tavares Fagundes1
1Universidade Federal de Minas Gerais (UFMG), Hospital das Clínicas, Departamento de Pediatria, Grupo de Gastroenterologia Pediátrica, Belo Horizonte, MG, Brazil.
Insights
In children with extrahepatic portal vein obstruction, medium- to large-caliber esophageal varices significantly increase bleeding risk. Endoscopic prophylaxis offers high eradication rates but relapses are common, highlighting the need for ongoing management of upper digestive hemorrhage.
Area of Science:
- Pediatric Gastroenterology
- Hepatology
- Vascular Surgery
Background:
- Extrahepatic portal vein obstruction (EHPVO) is a rare condition in children.
- Upper digestive hemorrhage (UDH) is a serious complication of EHPVO.
- Endoscopic prophylaxis is used to prevent UDH in these patients.
Purpose of the Study:
- To identify factors associated with UDH in children with EHPVO.
- To evaluate the outcomes of primary and secondary endoscopic prophylaxis for UDH in this population.
Main Methods:
- An observational, prospective study of 72 children with EHPVO from 2005 to 2017.
- Multivariate analysis to assess risk factors for UDH.
- Evaluation of efficacy and relapse rates of endoscopic prophylaxis.
Main Results:
- 69.4% of patients experienced at least one UDH episode.
- Medium- to large-caliber esophageal varices were associated with an 18-fold increased risk of UDH (p < 0.0001).
- High eradication rates for varices were observed with both primary (85.7%) and secondary (90.2%) prophylaxis, but relapse rates were significant (41.7% and 45.9%, respectively).
Conclusions:
- Endoscopic prophylaxis achieves high esophageal varix eradication but does not eliminate UDH risk due to potential bleeding from other sites.
- Medium- and large-caliber varices are key risk factors for UDH in pediatric EHPVO.
- This study is the first to assess bleeding risk factors in children with EHPVO.
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.
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