Prevention of gastroesophageal variceal bleeding in children: The role and efficacy of primary prophylaxis
Journal
Pediatrics and neonatology
Journal Volume
62
Journal Issue
3
Date Issued
2021-05
Author(s)
Abstract
Pediatricians face numerous challenges when managing gastroesophageal varices in cirrhotic children with chronic viral hepatitis and cholestatic liver disease.1Lee W.S. Song Z.L. Em J.M. Chew K.S. Ng R.T. Role of primary prophylaxis in preventing variceal bleeding in children with gastroesophageal varices.Pediatr Neonatol. 2021; 62: 249-257Scopus (1) Google Scholar, 2Wu J.F. Song S.H. Lee C.S. Chen H.L. Ni Y.H. Hsu H.Y. et al.Clinical predictors of liver fibrosis in patients with chronic hepatitis B virus infection from children to adults.J Infect Dis. 2018; 217: 1408-1416Crossref PubMed Scopus (11) Google Scholar, 3Chapin C.A. Bass L.M. Cirrhosis and portal hypertension in the pediatric population.Clin Liver Dis. 2018; 22: 735-752Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Prompt management of chronic viral hepatitis in children according to their risk may minimize the occurrence of viral hepatitis-related cirrhosis.2Wu J.F. Song S.H. Lee C.S. Chen H.L. Ni Y.H. Hsu H.Y. et al.Clinical predictors of liver fibrosis in patients with chronic hepatitis B virus infection from children to adults.J Infect Dis. 2018; 217: 1408-1416Crossref PubMed Scopus (11) Google Scholar The majority of chronic cholestatic liver diseases, particularly biliary atresia, are progressive and result in a large proportion of patients suffering from liver cirrhosis and related complications.3Chapin C.A. Bass L.M. Cirrhosis and portal hypertension in the pediatric population.Clin Liver Dis. 2018; 22: 735-752Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar,4Wu J.F. Lee C.S. Lin W.H. Jeng Y.M. Chen H.L. Ni Y.H. et al.Transient elastography is useful in diagnosing biliary atresia and predicting prognosis after hepatoportoenterostomy.Hepatology. 2018; 68: 616-624Crossref PubMed Scopus (37) Google Scholar Cholestatic liver disease remains the leading cause of liver transplant in children worldwide. However, the shortage of cadaveric livers has resulted in a long waiting period for liver transplants in children with cirrhosis and portal hypertension. Gastroesophageal variceal bleeding is one of the leading causes of morbidity and mortality in children with portal hypertension.1Lee W.S. Song Z.L. Em J.M. Chew K.S. Ng R.T. Role of primary prophylaxis in preventing variceal bleeding in children with gastroesophageal varices.Pediatr Neonatol. 2021; 62: 249-257Scopus (1) Google Scholar The risk of variceal bleeding is 12% in cirrhotic adults with gastroesophageal varices, and primary prophylaxis is recommended to prevent bleeding.3Chapin C.A. Bass L.M. Cirrhosis and portal hypertension in the pediatric population.Clin Liver Dis. 2018; 22: 735-752Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Although there is increasing evidence of non-invasive markers for predicting gastroesophageal varices in children, no pediatric guidelines have been proposed for surveillance of varices in cirrhotic children with portal hypertension who have an increased risk of bleeding.4Wu J.F. Lee C.S. Lin W.H. Jeng Y.M. Chen H.L. Ni Y.H. et al.Transient elastography is useful in diagnosing biliary atresia and predicting prognosis after hepatoportoenterostomy.Hepatology. 2018; 68: 616-624Crossref PubMed Scopus (37) Google Scholar,5Rahmani P. Farahmand F. Heidari G. Sayarifard A. Noninvasive markers for esophageal varices in children with cirrhosis.Clin Exp Pediatr. 2021; 64: 31-36Crossref PubMed Scopus (1) Google Scholar Endoscopic variceal ligation has largely been applied to successfully manage gastroesophageal varices in children, and endoscopic sclerotherapy has been used in infants and small children <10 kg.6dos Santos J.M. Ferreira A.R. Fagundes E.D. Ferreira A.P. Ferreira L.S. Magalhães M.C. et al.Endoscopic and pharmacological secondary prophylaxis in children and adolescents with esophageal varices.J Pediatr Gastroenterol Nutr. 2013; 56: 93-98Crossref PubMed Scopus (18) Google Scholar However, the role of primary prophylaxis remains unclear in the pediatric population and some problems remain unsolved. First, endoscopy is an invasive procedure in children, and the tolerance to a routine gastroesophageal varix survey in cirrhotic children with a bleeding tendency is poor. Second, endoscopic variceal ligation and sclerotherapy are quite difficult in children, particularly in infants and young children. Unfortunately, a shortage of manpower with good experience managing acute variceal bleeding in children remains a problem in some countries.1Lee W.S. Song Z.L. Em J.M. Chew K.S. Ng R.T. Role of primary prophylaxis in preventing variceal bleeding in children with gastroesophageal varices.Pediatr Neonatol. 2021; 62: 249-257Scopus (1) Google Scholar Hence, more evidence to demonstrate the safety and efficacy of routine primary prophylaxis in cirrhotic children is important. In this volume of The Journal, Lee et al. address these challenges by demonstrating the efficacy and safety of primary prophylaxis in children for preventing gastroesophageal variceal bleeding.1Lee W.S. Song Z.L. Em J.M. Chew K.S. Ng R.T. Role of primary prophylaxis in preventing variceal bleeding in children with gastroesophageal varices.Pediatr Neonatol. 2021; 62: 249-257Scopus (1) Google Scholar The utility of primary prophylaxis in cirrhotic children remains controversial.7Bozic M.A. Puri K. Molleston J.P. Screening and prophylaxis for varices in children with liver disease.Curr Gastroenterol Rep. 2015; 17: 27Crossref PubMed Scopus (7) Google Scholar This study demonstrated that cirrhotic children with primary prophylaxis are less likely to develop spontaneous bleeding than those with secondary prophylaxis.1Lee W.S. Song Z.L. Em J.M. Chew K.S. Ng R.T. Role of primary prophylaxis in preventing variceal bleeding in children with gastroesophageal varices.Pediatr Neonatol. 2021; 62: 249-257Scopus (1) Google Scholar Lee et al. also showed that cirrhotic children with primary prophylaxis need fewer additional endoscopic procedures and suggested routine screening endoscopy in all children who have signs of portal hypertension. More precise non-invasive predictors (such as FIB-4, APRI clinical score, transient elastography, or share wave elastography) need to be validated in children with portal hypertension. We may have an algorithm to survey high-risk children and provide adequate prophylaxis in those with portal hypertension with the guidance of precise predictors for high-risk gastroesophageal varices.
SDGs
Type
editorial