Comparative study of endoscopic variceal ligation and endoscopic variceal sclerotherapy in children with portal hypertension

ABSTRACT

Gastroesophageal variceal bleebing is a serious complication of portal hypertension. Endoscopic variceal Sclerotherapy [EVS] has been considered the mainstay of therapy for bleeding esophageal varices but it is associated with substantial local and systemic complications. However, recent data have shown that ehdoscopic variceal ligation [EVL] is just as efficacious and has fewer complications than EVS. Although there are many reports concerning EVL in adults, only a few studies have been done in children. The aim of this work was to compare the effectiveness and safety of endoscopic variceal ligation [EVL] and endoscopic variceal Sclerotherapy [EVS] in children with portal hypertension who had proved recent bleeding from esophageal varices. This study was conducted on 30 children [17 males and 13 females] with portal hypertension who had proved recent bleeding from esophageal varices. Their ages ranged from 5 to 18 years. They were selected from those admitted to the Hepatology Unit of Pediatric Department, Tanta University Hospitals. In this study all patients were subjected to the following full clinical history, thorough physical examination, routine abdominal ultrasonography as well as laboratory investigations. The latter included complete blood count, liver function tests, blood urea, serum creatinine and hepatitis markers. Upper gastrointestinal endoscopy was performed after resuscitation of bleeding patients for diagnosis and treatment of bleeding esophageal varices. Fifteen patients were treated with Sclerotherapy [Group I], and the other 15 patients were treated with band ligation [Group II]. Initial treatment for acute bleeding was followed by elective retreatment to eradicate varices. The patients were followed for a mean of 10 months, during which we determined the incidence of complications, the number of sessions needed to eradicate varices, rebleeding and recurrences of varices. Endoscopic Sclerotherapy and ligation were equally effective for the control of active variceal bleeding and no significant differences were found between the Sclerotherapy and ligation groups in arresting active index bleeding and achieving variceal eradication. The rate of variceal eradication in the EVS group was not significantly different from the EVL group [86.7% vs. 93.3%, respectively, P = 0.55], but band ligation eradicated varices more quickly than did Sclerotherapy [59.2 +/- 17 vs. 91.3 +/- 32.6 days, respectively, P = 0.0001] and in fewer endoscopic sessions [4.7 +/- 1.1 vs. 7.3 +/- 2.6, respectively, P= 0.0001]. The overall rate of rebleeding before variceal eradication wassignificantly higher in patients undergoing EVS than those undergoing EVL [39.9% vs. 6.6%, P = 0.034] as was the rate of major complications [46.2% vs. 6.6%, P =0.035] After eradication, esophageal variceal recurrence was not significantly different in patients treated by ligation than by sclerotherapy [21.4%% vs. 15.4%, P =0.927]. EVL is superior to EVS for acute and long-term management of bleeding esophageal varices because of its relative ease, faster obliteration, and lower complication and rebleeding rates. It appears that band ligation may replace sclerotherapy as the first choice for control of acute variceal bleeding and for eventual esophageal variceal eradication. Further long-term studies are needed to understand the evolution of variceal recurrence and portal hypertensive gastropathy in patients undergoing EVL