Endoscopic prophylaxis and factors associated with bleeding in children with extrahepatic portal vein obstruction

Oliveira, Ana Paula Pereira de; Ferreira, Alexandre Rodrigues; Fagundes, Eleonora Druve Tavares; Queiroz, Thaís Costa Nascentes; Carvalho, Simone Diniz; Franco Neto, José Andrade; Bittencourt, Paulo Fernando Souto

doi:10.1016/j.jped.2019.08.010

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Original article • J. Pediatr. (Rio J.) 96 (6) • Nov-Dec 2020 • https://doi.org/10.1016/j.jped.2019.08.010 copy

Endoscopic prophylaxis and factors associated with bleeding in children with extrahepatic portal vein obstruction^✰ ✰ Please cite this article as: Oliveira AP, Ferreira AR, Fagundes ED, Queiroz TC, Carvalho SD, Neto JA, et al. Endoscopic prophylaxis and factors associated with bleeding in children with extrahepatic portal vein obstruction. J Pediatr (Rio J). 2020;96:755–62.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

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.

KEYWORDS
Gastrointestinal hemorrhage; Esophageal varices; Portal hypertension

Factor	Group with UDH (n = 39)	Group without UDH (n = 25)	p
Sex n (%)
Boys	17 (43.6%)	15 (60%)
Girls	22 (56.4%)	10 (40%)	0.200^a a Asymptotic chi-squared test.

Age at first UDE
median (Q1; Q3)	4.4 (2.1; 6.5)	4.6 (3.1; 9.9)	0.109^b b Mann-Whitney test.

EV caliber, n (%)
Thin	3 (7.7%)^c c Standardized adjusted residuals ≤ -1.96.	15 (60%)^d d Standardized adjusted residuals ≥ +1.96.
Medium	21 (53.8%)^d d Standardized adjusted residuals ≥ +1.96.	7 (28%)^c c Standardized adjusted residuals ≤ -1.96.
Large	15 (38.5%)^d d Standardized adjusted residuals ≥ +1.96.	3 (12%)^c c Standardized adjusted residuals ≤ -1.96.	≤0.0001^a a Asymptotic chi-squared test.
Thin	3 (7.7%)	15 (60%)
Medium/Large	36 (92.3%)	10 (40%)	≤0.0001^a a Asymptotic chi-squared test.

Red spot, n (%)
Yes	15 (38.5%)	6 (24%)
No	24 (61.5%)	19 (76%)	0.229^a a Asymptotic chi-squared test.
Gastric varices, n (%)
Yes	22 (56.4%)	5 (20%)
No	17 (43.6%)	20 (80%)	0.004^a a Asymptotic chi-squared test.

PHG, n (%)
Yes	12 (30.8%)	10 (40%)	0.448^a a Asymptotic chi-squared test.
No	27 (69.2%)	15 (60%)

Platelets	113,000	118,000
median (Q1; Q3)	(78,500; 161,500)	(85,500; 170,000)	0.835^b b Mann-Whitney test.

INR
median (Q1; Q3)	1.2 (1.1; 1.4)	1.1 (1.0; 1.4)	0.393^b b Mann-Whitney test.

Factor	OR	95% CI	p
Female sex	1.94	0.70-5.38	0.203
Age at first UDE ≤5 years	1.33	0.48-3.65	0.584
Caliber of EV - medium/large	18	4.33-74.76	<0.0001
Presence of red spots	1.98	0.64-6.08	0.233
Presence of gastric varices	5.18	1.61-16.62	0.006
Presence of PHG	0.67	0.23-1.91	0.449
Platelets <150,000	0.72	0.24-2.16	0.556
Platelets <100,000	0.81	0.26-2.53	0.720
Platelets <50,000	1.70	0.18-16.35	0.646
INR ≥1.3	0.77	0.25-2.36	0.646

	Primary prophylaxis (n = 14)	Secondary prophylaxis (n = 41)
Sex, n (%)
Boys	8 (57.1%)	20 (48.8%)
Girls	6 (42.9%)	21 (51.2%)

Age at first symptoms (years)
median (Q1; Q3)	1.6 (0.8; 4.1)	2.1 (1.1; 4.2)

Age at onset of prophylaxis (years)
Median (Q1; Q3)	6.3 (3.6; 14.1)	5.1 (2.4; 7.3)

Method, n (%)
Ligation	14 (100%)	17 (41.5%)
Sclerotherapy	0	24 (58.5%)

EV eradication, n (%)	12 (85.7%)	37 (90.2%)
Number of sessions required to eradicate
median (Q1; Q3)	3.5 (2.0; 4.0)	4.0 (3.3; 6.0)

EV Relapse, n (%)	5 (41.7%)	17 (45.9%)
Time to relapse (years)
median (Q1; Q3)	1.8 (0.9; 2.6)	1.7 (0.9; 3.4)

Bleeding after the onset of prophylaxis, n (%)	2 (14.3%)	14 (34.1%)
Early	2 (100%)	13 (92.9%)
Late	0	1 (7.1%)

Presence of previous GV, n (%)	0	11 (26.8%)
Development of GV, n (%)	8 (57.1%)	16 (53.3%)
Presence of previous PHG, n (%)	9 (64.3%)	13 (31.7%)
Development of PHG, n (%)	4 (80%)	26 (92.9%)
Length of follow-up (years) mean ± SD	5.7 ± 3.1	9.1 ± 5.8

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[1] ∗ Corresponding author. anappol@gmail.com (A.P. Oliveira).