Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia; Paediatrics and Child Health Research Group, University Malaya, Kuala Lumpur, Malaysia.
Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia.
Pediatr Neonatol. 2021 May;62(3):249-257. doi: 10.1016/j.pedneo.2021.01.002. Epub 2021 Jan 19.
Primary endoscopic prophylaxis in pediatric gastroesophageal varices is not universally practiced. We aimed to determine the role of primary endoscopic prophylaxis in preventing variceal bleeding in gastroesophageal varices in children.
We reviewed all children with gastroesophageal varices seen in our unit from 2000 to 2019. Primary prophylaxis was defined as endoscopic procedure without a preceding spontaneous bleeding and secondary prophylaxis as preceded by spontaneous bleeding. High-risk varices were defined as presence of grade III esophageal varices, cardia gastric varices or cherry red spots on the varices. Outcome measures (spontaneous rebleeding within 3 months after endoscopic procedure, number of additional procedures to eradicate varices, liver transplant [LT], death) were ascertained.
Sixteen of 62 (26%) patients (median [± S.D.] age at diagnosis = 5.0 ± 4.3 years) with varices had primary prophylaxis, 38 (61%) had secondary prophylaxis while 8 (13%) had no prophylaxis. No difference in the proportion of patients with high-risk varices was observed between primary (88%) and secondary (92%; P = 0.62) prophylaxis. As compared to secondary prophylaxis, children who had primary prophylaxis were significantly less likely to have spontaneous rebleeding (6% vs. 38%; P = 0.022) and needed significantly fewer repeated endoscopic procedures (0.9 ± 1.0 vs. 3.1 ± 2.5; P = 0.021). After 8.9 ± 5.5 years of follow-up, overall survival was 85%; survival with native liver was 73%. No statistical difference was observed in the eventual outcome (alive with native liver) between primary and secondary (71% vs. 78%, P = 0.78).
Children with PHT who had primary prophylaxis had less subsequent spontaneous rebleeding and needed fewer additional endoscopic procedures as compared to secondary prophylaxis but did not have an improved eventual outcome. Screening endoscopy in all children who have signs of PHT and primary prophylaxis in high-risk esophageal varices should be considered before eventual LT.
小儿胃食管静脉曲张的一级内镜预防措施并未普遍实施。我们旨在确定一级内镜预防措施在预防小儿胃食管静脉曲张出血中的作用。
我们回顾了 2000 年至 2019 年在我们科室就诊的所有胃食管静脉曲张患儿。一级预防定义为未经先前自发性出血的内镜操作，二级预防定义为先前有自发性出血。高危静脉曲张定义为存在 III 级食管静脉曲张、贲门胃底静脉曲张或静脉曲张上的樱桃红点。确定了（内镜操作后 3 个月内自发性再出血、消除静脉曲张的附加操作次数、肝移植 [LT]、死亡）等结局指标。
62 例静脉曲张患儿中，16 例（诊断时的中位年龄[±标准差]为 5.0 ± 4.3 岁）进行了一级预防，38 例（61%）进行了二级预防，8 例（13%）未进行预防。一级（88%）和二级（92%；P=0.62）预防中高危静脉曲张患者的比例无差异。与二级预防相比，一级预防的患儿自发性再出血的可能性显著降低（6%比 38%；P=0.022），且需要的重复内镜操作次数显著减少（0.9 ± 1.0 比 3.1 ± 2.5；P=0.021）。随访 8.9 ± 5.5 年后，总体生存率为 85%；保留原肝的生存率为 73%。一级和二级预防的最终结局（保留原肝存活）无统计学差异（71%比 78%，P=0.78）。
与二级预防相比，一级预防的 PHT 患儿随后自发性再出血较少，需要额外的内镜操作较少，但最终结局并未改善。对于有 PHT 迹象的所有儿童，应考虑进行筛查性内镜检查，并在最终 LT 前对高危食管静脉曲张进行一级预防。
