What is the role for preventing variceal bleeding in Biliary Atresia?

During medical school, I read a book called “The House of God”  (The House of God – Wikipedia, the free encyclopedia.  One of this cynical book’s premises is that doing more diagnostic tests and treatments to help patients actually harms them.

A recent study of children with biliary atresia reminded me of this premise (Gastroenterol 2013; 145: 801-7, eidtorial 719-22).   In this retrospective study, there were 66 children with endoscopic evidence of portal hypertension who underwent endoscopic therapy for either primary (n=36, mean age 22 months) or secondary (n=30, mean age 24 months) treatment of esophageal varices biliary atresia (2001-2011).  These children were at high risk for bleeding; they had a mean bilirubin of >10 mg/dL and 20% had ascites.

Results:

Primary prophylaxis group: mean of 4.2 sessions were needed to eradicate varices.  Varices reappeared in 37%; there was no breakthrough bleeding.  97% survived for 3 years.  All of these patients had varices grade 2 or higher and 94% had red wale markings.

Secondary prophylaxis group (after previous bleeding): mean of 4.6 sessions to eradicate varices.  Varices reappeared in 45% and 10% had breakthrough bleeding.  84% survived for 3 years.

Treatment:

  • For bleeding group, sclerotherapy was used in 73%, banding in 17%, and both in 10%.
  •  For prophylaxis group, sclerotherapy was used in 44%, banding in 41%, and both in 14%.
  • By the end of the study, sclerotherapy was mainly used in patients weighing less than 8 kg.
  • Each endoscopy session had the same endoscopist, used octreotide (2 mcg/kg/hr) an 1 hour before and then for 2-3 days afterwards.
  • With bleeding patients, these sessions occurred after the patient was stabilized, with a mean of 10 days afterwards.
  • Patients had an average of four 3-day hospitalizations.
  • Within an average of 14 months, more than half of the primary prophylaxis group had undergone transplantation

The authors interpret their data as follows:  “primary or secondary prophylaxis of bleeding is well tolerated and greatly reduces the risks of variceal bleeding in children with biliary atresia and high-risk gastroesophageal varices.  The results support the active detection of these signs by endoscopic procedures.”

In contrast, the editorial is much less supportive of primary prophylaxis.  “We need to weigh the risks and benefits of multiple procedures in a nonbleeding child who may not bleed for years, when varices have a high chance of recurring and transplant is sometimes imminent. Because mortality from gastrointestinal bleeding in children is quite low (zero in this small study), we may need to consider a ‘wait and see’ approach.”

Bottomline: A failed Kasai is an indication for transplantation which is a much more definitive treatment for portal hypertension.

Previous related blog posts:

3 thoughts on “What is the role for preventing variceal bleeding in Biliary Atresia?

  1. Pingback: NASPGHAN Postgraduate Course 2014 -Endoscopy Module | gutsandgrowth

  2. Pingback: Esophageal Varices and Primary Prophylaxis | gutsandgrowth

  3. Pingback: Bad News Bili | gutsandgrowth

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