Esophageal Varices and Primary Prophylaxis

This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

One of the topics debated at this year’s meeting was the issue of whether it is worthwhile for patients with esophageal varices to undergo primary prophylaxis.

Here’s a summary:

Esophageal Banding: Proactive vs Expectant Waiting Maureen Jonas (Boston Children’s) and Karen Murray (Seattle Children’s)

Reviewed definitions of portal hypertension. Hepatic venous portal gradient (HVPG) >12 associated with variceal bleeding is the standard in adult medicine.

Management issues: primary prophylaxis, treatment of acute bleeding, and secondary prophylaxis.

Adult Data/Guidelines:

  • 1-year rate of first bleeding 5% for small varices and 15% for large varices
  • 1-year recurrent variceal bleeding ~60%
  • Compensated cirrhotics with small high-risk varices (or mod-large varices): consider treatment with beta-blocker (and/or EVL for mod-large varices).
  • Beta-blockers and EVL –similar efficacy and survival in adults.
  • Lowering HVPG by 20% lowers risk of complications
  • Beta-blockers stopped in ~20% of adults due to side effects like fatigue or shortness of breath.

Pediatrics and Beta-Blockers:

  • Beta-blockers have good safety in children in a wide range of conditions –cardiomyopathy, migraines, others. HVPG is used in adults but is very invasive.
  • Pediatric HVPG correlation to variceal development is not yet established.
  • Bleeding from varices –17-29% in biliary atresia (BA) patients over 10 years. Yearly rates: 2-9%.
  • Mortality in pediatrics from bleeding varices: 2-5% with BA, 0-2% with portal vein thrombosis.

Non-Selective Beta-blockers.

  • There are adverse effects: hypotension, bronchospasm, hypoglycemia. Am Gastroenterol 2014; 27: 20-6.  In infants/pediatric patients with shock, tachycardia is the primary response. Beta-blockers interfere with this.
  • In pediatric studies, bleeding risk has not been proven to be reduced with non-selective Beta-Blockers.

Risks of primary prophylaxis with banding or sclerotherapy:

  • Adverse effects: could convert a child not prone to bleeding into one prone to bleeding. Stricture possible.
  • Efficacy? Limited data.  Study on prophylactic sclerotherapy if grade 2/3. Median followup was only 1.7 years. JPGN 2012; 55:574
  • Sometimes cannot eradicate varices and/or recur quickly. Gastroenterol 2013; 145: 801.

Rebuttal:

  • Sometimes we have to extrapolate from adult data
  • Currently about half of pediatric GIs use primary prophylaxis in these cases (JPGN 2011; 52: 751)

Take-home message: insufficient data to demonstrate efficacy of primary prophylaxis as well as to demonstrate adverse effects of primary prophylaxis.

Related blog posts:

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