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Echocardiography, Bile Acids and Spleen Stiffness to Rule Out High-Risk Varices in Children With Biliary Atresia
Virginie Lambert1,2, Jean-Paul Teglas3, Oanez Ackermann4,5
1Cardiologie Congénitale Montsouris, Institut Médico-Chirurgical Montsouris, Paris, France.
Insights
This study introduces non-invasive tools to detect high-risk gastroesophageal varices in children with biliary atresia, aiming to reduce invasive endoscopies. Combining echocardiography and bile acid levels for younger children, and spleen stiffness for older ones, can significantly decrease screening needs.
Area of Science:
- Pediatric Gastroenterology
- Hepatology
- Medical Imaging
Background:
- Biliary atresia often leads to gastroesophageal varices (GEV) with high bleeding risk (HRV) in children.
- Early screening via endoscopy is crucial for prophylaxis but is invasive and costly.
- Developing non-invasive tools to rule out HRV is essential to minimize endoscopic procedures.
Purpose of the Study:
- To identify non-invasive markers for ruling out HRV in children with biliary atresia.
- To reduce the frequency of diagnostic endoscopies in this pediatric population.
- To improve the efficiency and reduce the burden of GEV screening.
Main Methods:
- Prospective enrollment of 100 children with biliary atresia and portal hypertension.
- Utilized laboratory tests, transient elastography, echocardiography, and endoscopy.
- Applied principal component analysis and multivariate logistic regression for HRV prediction.
Main Results:
- Higher indexed right atrium area, left ventricle end-diastolic diameter, younger age, elevated serum bile acid, and increased spleen stiffness were linked to HRV.
- A combined echocardiography and serum bile acid model spared 37% of endoscopies in children under 3 years without missing HRV.
- Spleen stiffness ≤30 kPa spared 41% of endoscopies in children over 3 years without missing HRV.
Conclusions:
- A tailored approach combining echocardiography and bile acid levels for younger children and spleen stiffness for older children can effectively screen for HRV.
- This strategy may reduce screening endoscopies by approximately 40% in children with biliary atresia and portal hypertension.
- Non-invasive methods offer a promising alternative to routine endoscopy for GEV surveillance.
Background And Aims:
Detecting gastroesophageal varices with a high risk of bleeding (HRV) in children with biliary atresia requires endoscopies from an early age to apply primary prophylaxis of bleeding. However, repeated endoscopies are invasive and costly. This study was performed to define tools to rule out HRV, with the objective of reducing the number of endoscopies.
Methods:
Children with biliary atresia and portal hypertension were prospectively enrolled. Laboratory tests, elastography, echocardiography, and endoscopy were performed. Variables were subjected to principal component analysis, followed by multivariate logistic regression analyses for HRV prediction. The effectiveness of composite models and criteria based on liver and spleen stiffness measurements was evaluated using the missed HRV ratio and the spared endoscopy rate.
Results:
Among the 100 children enrolled, a higher indexed right atrium area, higher left ventricle end-diastolic diameter, younger age, higher serum bile acid concentration, and higher spleen stiffness were independently associated with HRV. In children under 3 years old, a model combining indexed right atrium area from echocardiography and serum bile acid concentration achieved a 37% spared endoscopy rate with no missed HRV. For children over 3 years old, spleen stiffness of ≤ 30 kPa was associated with a 41% spared endoscopy rate and no missed HRV.
Conclusion:
Combining an echocardiography-based model for children under 3 years old with spleen stiffness criteria for older children may reduce the need for screening endoscopies by 40% in children with biliary atresia and portal hypertension.
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