Treatment of portal hypertension in children

The management of children with portal hypertension (PH) has substantially changed owing to the good results and broader application of both endoscopic sclerotherapy and orthotopic liver transplantation (OLT). Since the introduction of sclerotherapy for the treatment of bleeding esophageal varices, the number of surgical procedures has sharply decreased. Until the early 1980s, however, the treatment of choice of bleeding esophageal varices was based on different variations of two main types of open surgery: devacularization and transection operations and portosystemic shunts. The experience with nonshunt procedures is limited in the pediatric population. Literature reports from the last 25 years have emphasized a number of restrictions related to portosystemic shunts in small subjects. However, portosystemic shunts, selective or not, can be performed even in very young subjects with high rates of success. From 1974 to 1984 the distal splenorenal shunt (DSRS) was the procedure of choice for the treatment of children with variceal bleeding in our institution. Forty‐two children underwent DSRS during this period. Since 1985, when endoscopic variceal sclerotherapy (EVS) replaced DSRS as the first therapeutic option in our service, this shunt has been performed in only 8 children in whom EVS has failed, none of them during the last 2 years. In this cohort of 50 cases of DSRS, the shunt patency has increased from 71% in the first 7 patients to 95% thereafter. There has been no perioperative mortality. From 1985 to April 1993, 107 children were submitted to EVS sessions for the treatment of esophageal varices bleeding. Among the first 62 patients, complete obliteration of the varices was obtained in 85%, and the incidence of upper gastrointestinal (GI) hemorrhage before total obliteration of the varices was 53%. In the next 45 children, such indexes changed to 96% and 18%, respectively, due to the shorter interval between EVS sessions applied in this group. Currently, we are conducting a prospective, randomized, trial to evaluate the prophylactic value of EVS: 49 patients have received such prophylaxis, and 28 have not (controls). There has been no statistically significant difference in the incidence of upper GI hemorrhage in the two groups: respectively, 6% and 7%. However, the source of bleeding has been different in each group, being always variceal in the control group and hemorrhagic gastritis in the prophylaxis group. conclusion: (1) EVS is safe and highly effective for the control of esophageal bleeding from PH in children. It is currently the first option of treatment; (2) DSRS still plays an important role in the management of PH in the pediatric population. It is the procedure of choice in cases of EVS failure; (3) Although prophylactic sclerotherapy can prevent only esophageal varices hemorrhage in children with PH, it has not proved to decrease the incidence of upper GI hemorrhage up to this time; (4) OLT is the only definitive treatment of end‐stage liver disease, with or without previous portosystemic shunt.