Management of childhood esophageal varices: learnings from an advanced medical centre

Background: Variceal bleeding represents a significant clinical emergency with potential life-threatening implications in infants and children. Endoscopic band ligation is the standard treatment for esophageal varices. Objective: The objective is to evaluate the effectiveness of band ligation for managing esophageal varices in both extra-hepatic and hepatic cases of portal hypertension. Methods: A prospective study was conducted in the Department of Pediatric Gastroenterology, Hepatology & Nutrition, Bangladesh Shishu Hospital & Institute, Dhaka, Bangladesh on 56 pediatric cases of esophageal varices enrolled from January 2021 to December 2023. All of them were treated with EVL and tab. Propranolol thereafter. Later followed up for a minimum period of one year from 1st session of EVL. Results: The study included 56 children aged 2 to 18 years, with a mean age of 8 ± 1.96 years and a male-to-female ratio of 1.8:1. Among them, 43 children (77%) had pre-hepatic causes of portal hypertension, while 13 (23%) had hepatic causes associated with chronic liver disease. Band ligation was completed in a single session for 10 (23.26%) pre-hepatic cases, whereas all hepatic cases required multiple sessions. On average, 2-3 bands were applied per session in both groups. Grade II esophageal varices with red signs were more frequently observed in pre-hepatic cases, while more severe varices (Grade III and IV) were predominantly found in hepatic cases. Gastric varices were more common in hepatic cases (4, 30.77%) compared to pre-hepatic cases (6, 13.95%). Recurrent bleeding occurred in 15 (35%) of the pre-hepatic cases and in all hepatic cases (100%). Early re-bleeding was more prevalent among hepatic cases (6, 46.15%), whereas late re-bleeding was noted in both groups-11 (25.58%) pre-hepatic and 7 (53.85%) hepatic cases. Minor complications such as discomfort were reported in 7 (16.28%) pre-hepatic and 3 (23.08%) hepatic cases. Nausea and vomiting were the most commonly observed post-procedural symptoms in both groups. Only one child (2.33%) from the pre-hepatic group experienced a major complication, which was the development of an esophageal stricture. Conclusion: Pre-hepatic causes were the most common etiology of portal hypertension in children. Endoscopic band ligation was effective and safe, requiring fewer sessions in pre-hepatic cases, and showed higher re-bleeding rates and severity in hepatic cases.