Use and safety of prophylactic endoscopy from a single center serving urban and rural children with portal hypertension

Voytek Slowik,Ryan T Fischer,Anissa Bernardez,Tassos Grammatikopoulos,James F Daniel,Heather Wasserkrug

doi:10.1038/s41598-021-03759-x

Abstract

Prophylactic endoscopy is routine in adults with portal hypertension (PHTN), but there is limited data in pediatrics. We sought to describe our experience with prophylactic endoscopy in pediatric PHTN. This is a retrospective study of 87 children who began surveillance endoscopy prior to gastrointestinal bleeding (primary prophylaxis) and 52 who began after an episode of bleeding (secondary prophylaxis) from 01/01/1994 to 07/01/2019. Patients who underwent primary prophylaxis had a lower mean number of endoscopies (3.897 vs 6.269, p = 0.001). The primary prophylaxis group was less likely to require a portosystemic shunt (6% vs 15%, p < 0.001) with no difference in immediate complications (1% vs 2%, p = 0.173) or 2-week complications (1% vs 2%, p = 0.097). No deaths were related to variceal bleeding or endoscopy. Kaplan–Meier Survival Curve suggests improved transplant and shunt free survival in the primary prophylaxis group (log-rank p < 0.001). Primary and secondary endoscopic prophylaxis should be considered safe for the prevention of variceal hemorrhage in pediatric portal hypertension. There are differences in outcomes in primary and secondary prophylaxis, but unclear if this is due to patient characteristics versus treatment strategy. Further study is needed to compare safety and efficacy to watchful waiting.

Highlights

Prophylactic endoscopy is routine in adults with portal hypertension (PHTN), but there is limited data in pediatrics
Of patients who underwent endoscopy and had a diagnosis of PHTN, we identified 87 subjects who underwent primary prophylaxis endoscopy and 52 in the secondary prophylaxis group
Gastroesophageal varices develop as the portosystemic gradient (PSG) rises to > 10 mmHg in adults and a PSG > 12 mmHg is predictive of those adults who will develop variceal hemorrhage, pediatric confirmatory data are lacking and children may develop complications at lower gradients than adults[3,9,10]

Summary

Introduction

Prophylactic endoscopy is routine in adults with portal hypertension (PHTN), but there is limited data in pediatrics. We sought to describe our experience with prophylactic endoscopy in pediatric PHTN This is a retrospective study of 87 children who began surveillance endoscopy prior to gastrointestinal bleeding (primary prophylaxis) and 52 who began after an episode of bleeding (secondary prophylaxis) from 01/01/1994 to 07/01/2019. Primary and secondary endoscopic prophylaxis should be considered safe for the prevention of variceal hemorrhage in pediatric portal hypertension. The underlying causes are variable and include portal vein thrombosis, mass effect, intrinsic liver disease and cirrhosis, among others This increased resistance leads to an elevated portosystemic gradient (PSG) resulting in the development of varices as blood travels through shunts to bypass the obstructed portal system and return to venous circulation. In adults with PHTN without an episode of bleeding, there are recommendations for primary preventative endoscopy to reduce the morbidity and mortality from variceal b.

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Results

Conclusion