Result of eradication of esophageal varices in children with extra hepatic portal venous obstruction in Sudan

ABSTRACT

Extra hepatic Portal Vein Thrombosis is the main cause of Portal hypertension in children in Sudan, which is responsible for almost 30% of heamatemsis in children in Sudan. Treatment is targeted at the complications and includes primary and secondary prophylaxis against upper gastrointestinal bleeding [which results from the rupture of esophageal varices] which is usually a combination of endoscopic sclerotherapy and/or band ligation to eradicate the varices, Porto systemic shunting in selected cases, medical prophylaxis, and to support the child growth and development. In this study we looked beyond the eradications of the varices in these children to help us providing a better long term care plan for such an important problem. The Objectives are to find out the recurrence of esophageal varices, evolution of gastric varices, portal hypertensive gastropathy [PHG] and risk of rebleeding following esophageal variceal eradication in children with Extra hepatic Portal Vein Obstruction [EHPVO]. Between March 2005 and March 2010, children with extra hepatic portal venous obstruction [EHPVO] and bleeding from esophageal varices who referred to the Gastroentrology unit at Gafaar In Oaf Specialized Children Hospital, Khartoum, Sudan, and the Endoscopic unit of the Military hospital, Omderman, Sudan received endoscopic injection sclerotherapy [EIS] and /or Esophageal Varices Band Ligation [EVBL] until eradication. Surveillance endoscopy was performed initially at 3 months and subsequently at intervals of 6 months to one year to detect esophageal and gastric varices, and PHG. Gastric varices were classified as gastroesophageal [GOV] or isolated gastric varices [IGV]. Gastroesophageal varices included types GOV1 and GOV2 that extend along lesser and greater curvatures respectively. Patients who had recurrence of bleeding were evaluated by emergency upper gastrointestinal endoscopy. The therapeutic endoscopy procedures were done by the two authors. 113 of 133 children who achieved esophageal varices eradication were evaluated. Esophageal varices recurred in 40% cases. Primary gastric varices [before EIS/EVBL] were seen in 61% cases [GOV98% [83% GOV1, 15%GOV2] and IGV2%] and secondary gastric varices [after EIS/EVBL] in 28% [GOV 71% [47% GOV1, 24% GOV2] and IGV 29%]. Secondary gastric varices were distributes as 20% GOV1, 42% GOV2 and 87% IGV. Frequency of gastric varices before sclerotherapy or/and banding, at the last follow up showed decrease in GOV1 from 57to 39 [P=0.01], increase in GOV2 from 10 to 16 and increase in IGV from 1 to 10 [P<0.001]. PHG increased in frequency from 12% to 41% [P<0.001] and severity from one patient to 12 [P<0.001]. Eight cases had rebleeding from gastric varices [4 GOV1, 3 GOV2 and 1 IGV]. It was conclude that following esophageal variceal eradication in children with EHPVO a significant decrease in Gastroesophageal Varices, increase in Isolated Gastric Varices and increased frequency and severity of Portal hypertensive Gastropathy takes place. Small rebleeding risk persists from gastric varices irrespective of the type