Huma Arshad Cheema, Anjum Saeed, Arit Parkash, Hassan Suleman, Zafar Fayyaz.
Etiology and Management of Bleeding Esophageal Varices in Children: Our Experience at Tertiary Care Hospital.
Pak Paed J Jan ;38(4):223-9.

Objective: To evaluate children with bleeding from esophageal varices due to different causes and management aspects. Study Design: Descriptive case series Settings and Duration of Study: Gastroenterology, Hepatology and Nutrition department of The Children’s Hospital and Institute of Child Health Lahore, from Jan 2000 to December 2011. Methodology: We included the children with esophageal varices due to different causes of portal hypertension over a period of twelve years. Diagnosis was made on clinical history, physical examination and investigations including Doppler Ultrasound and endoscopy of all included children. Children with other causes of bleeding like gastric ulcer, duodenal ulcer and malignancies of gastrointestinal tract were excluded from study. Clinical, biochemical features and coagulation profile on presentation, and underlying etiology of variceal bleeding were recorded. Institution of medical therapy, endoscopic therapy and surgery were also recorded. Data was analyzed for clinical profile, etiology, investigations, management given and outcome. Results: This study included 408 patients, 259 (63.4%) males and 149 (36.6%) females. Etiologies were portal vein thrombosis (PVT) 303 (74.2%) patients, chronic liver disease 74 (18.1%), Budd Chiari syndrome 28 (6.9%) and congenital hepatic fibrosis 3 (0.7%). Our large group was PVT (n=303). Out of 303 bleeders with PVT, in 218 (72%) acute bleeding episode could be controlled by medical management. Regarding endoscopic intervention, 122 (40.3%) had sclerotherapy, variceal obliteration was achieved in 104(85%). Complications post-sclerotherapy were transient fever in 75 (61%), esophageal strictures in 1(0.8%) and esophageal perforation in 1(0.8%). EBL was performed in 91 (30.3%) patients and variceal obliteration was achieved in 79(87%). Combination of EBL and sclerotherapy were performed in 90 (29.7%) and variceal obliteration was achieved in all patients. 30(10%) patients were referred for shunt surgery that underwent sclerotherapy (n=18) or band ligation(n=12) and had significant rebleeds but none of the patients in the combination group required to have shunt surgery. Three patients of PVT expired due to uncontrolled bleeding and 30 patients with chronic liver disease expired and one patient of congenital hepatic fibrosis was referred for shunt surgery and expired due to massive bleeding. Conclusion: The commonest cause for portal hypertension in children is pre-hepatic due to portal vein thrombosis. Conservative medical management including octeriotide was successful in controlling acute bleeding episode in 72% of patients of portal vein thrombosis. Elective or emergency sclerotherapy and EBL are safe and efficacious interventions in children.

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