Esophageal sclerotherapy: An effective modality in children

During the past five years, sclerotherapy has been used at our institution in 13 children for the management of recurrent major variceal bleeding. The varices were secondary to extrahepatic portal hypertension in seven patients and to intrahepatic portal hypertension in the remaining six. Sclerotherapy was performed under direct vision using either rigid or flexible endoscopic equipment, and the sclerosing agents were injected directly into the varices. The average age at initiation of sclerotherapy was 9 years (range: 1 to 19 years). The follow-up has ranged from 2 to 4 1/2 years with a mean of 3 1/2 years. Complete obliteration of all varices was obtained in eight of these patients. Two children have minimal residual varices, in one of whom 17 sclerotherapy procedures have been performed to date. One additional patient had a severe episode of bleeding during esophagoscopy, and transesophageal ligation of varices was required for control. Two patients have died following initiation of sclerotherapy. In neither case was the death the result of bleeding esophageal varices or a complication of endosclerosis. Bleeding from varices was the major clinical problem in all of these children, and this problem has been largely corrected by the sclerotherapy program. With one exception, there have been no episodes of variceal bleeding requiring transfusion in these patients following intiation of this therapy. One child developed an esophageal ulcer postinjection, but none have developed esophageal strictures. One patient developed an allergic reaction to the sclerosant that was treated during subsequent injections, with prior administration of an antihistamine (diaphenhydramine chloride) and steroids. Nine of 13 children have shown evidence of distal esophagitis that has been well controlled with medical therapy. Esophageal sclerotherapy is a safe and effective method of management for control of bleeding esophageal varices in children. The majority of patients have achieved effective control of their recurrent hemorrhage, and no significant long-term sequelae have been recognized. This method of management has the obvious advantages of avoiding extensive surgical procedures required for a shunt or some of the direct operations (eg. portoazygous disconnection). Clearly it is applicable for young children whose veins are deemed too small for a shunt and for those in whom a shunt has either failed or who are "unshuntable." In children with intrahepatic disease for whom a liver transplant may eventually be required, sclerotherapy may well be the preferred method of controlling bleeding varices.