Tag Archives: primary prophylaxis

Natural History of Varices in Children

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O Ackermann et al. Gastroenterol 2026; 170: 188-198. The Natural History of Gastroesophageal Varices in Children With Portal Hypertension

Methods: Retrospective review of 1586 children with portal hypertension. 590 had two or more upper endoscopies (403 with biliary atresia).

“For the purpose of this study, and based on our previous experience in children,8,11 the endoscopic pattern associated with a high risk of bleeding (ie., HRV) included grade 3 esophageal varices as well as grade 2 esophageal varices with red color signs or gastric varices (cardia), or both.” 

The authors developed a HRV [high risk of varices] score as a composite index calculated as follows: 1 point for grade 1 esophageal varices, 2 points for grade 2 varices, 3 points for grade 3 varices, and 1 point each for the presence of red color signs or GOV1 (HRV score range, 0–5). High-risk varices had an HRV score of 3 to 5.

Key findings:

  • Worsening of the endoscopic pattern occurred in 58% of children over a mean 4-year interval
  • 5- and 10-year probabilities of HRV emergence in initially HRV-negative children were 36% and 54%, respectively
  • Infants with biliary atresia are at particularly high risk with correlation to the degree of cholestasis (see below)
  • Platelet count less than 150,000 as an indicator of HRV was mainly useful in older children. “A platelet count of ≥150,000/mm3 was recorded in 205 of the 629 children (32%) with HRV. Moreover, there was a decrease with age in the proportion of children with HRV and a platelet count of ≥150,000/mm3, falling from 62% in children aged <12 months to 2% in patients aged >10 year.” 16% of children 6-8 yrs, 12% of children 8-10 years of age with HRV had platelet count ≥150,000/mm3
  • “Gastrointestinal bleeding was recorded in 36 of 947 children (3.8%) who did not have HRV at their last endoscopy and in 270 of the 359 children (75%) with HRV at their last endoscopy who did not undergo endoscopic or surgical primary prophylaxis of bleeding.”
Bilirubin of 100 micoMol is equivalent to 5.8 mg/dL and 17.1 is eqivalent to 1 mg/dL

Discussion Points:

  • Variceal progression was much faster in infants and is  is likely due to the severity of cholestasis and its impact on portal hypertension.
  • “It is notable that children with Alagille syndrome and those with genetic cholestasis with normal GGT have a lower rate of variceal progression and a lower mean HRV score than children with biliary atresia, despite comparably high levels of bilirubin. This suggests that different mechanisms of cholestasis … may have distinct consequences on intrahepatic portal vein branches resulting in varying degrees of portal hypertension.”
  • “In children with biliary atresia aged <12 months, grade 2 esophageal varices without red color signs or GOV1 (HRV score of 2) should be considered an indication for endoscopic primary prophylaxis.”
  • “Because the efficacy and safety of β-blockers have not been established in children, we suggest that this pattern—grade 1 varices with red color signs or GOV1—should prompt early repeat endoscopy to detect HRV in a timely manner…this repeat endoscopy could be recommended 6 months after the previous one.”
  • Limitations: High proportion of children with biliary atresia (limits conclusions with other disorders), and retrospective study since 1990
  • “Pending the results of future studies, the detection of palpable splenomegaly remains a simple and practical criterion for initiating screening endoscopy in children with portal hypertension”

My take: This is a very useful study providing important data to help improve decision-making in children with portal hypertension.

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Why Carvedilol Is Considered Best Pharmaceutical Agent to Prevent Variceal Bleeding (in Adults)

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M Jachs et al. Clin Gastroenterol Hepatol 2023; 21: 2318-2326. Open Access! Carvedilol Achieves Higher Hemodynamic Response and Lower Rebleeding Rates Than Propranolol in Secondary Prophylaxis

Associated editorial: J Bosch. Clin Gastroenterol Hepatol 2023; 21:2195-2196. Open Access! Carvedilol as Best β-Blocker for Secondary Prophylaxis of Variceal Bleeding: Are We There, or Not Yet?

Key findings:

  • In a retrospective cohort comprising 87 adult patients receiving NSBB (non-selective beta blocker) in addition to band ligation after variceal bleeding, carvedilol induced more profound decreases in hepatic venous pressure gradient compared with propranolol. The higher rate of chronic hepatic venous pressure gradient response to carvedilol (53.3% vs 28.6%; P = .034) was paralleled by lower rates of variceal rebleeding, liver-related death, and further nonbleeding decompensation.

In the discussion and the editorial, it is noted that there is high-quality evidence that carvediol is superior for primary variceal prophylaxis in adults. “Carvedilol increasingly is used for the prevention of variceal bleeding, 2 and, based on the recent landmark PREDESCI study, overall hepatic decompensation/ascites3 in compensated cirrhosis, because it induces HVPG response (a ≥10% decrease in HVPG is sufficient in primary prophylaxis17) in up to 75% of patients vs 50% when using propranolol. However, it induces more pronounced decreases in blood pressure, which may be detrimental in patients with (refractory) ascites.15“

Though there are concerns about dropping blood pressure, the editorial notes that “up to two-thirds of patients with compensated cirrhosis” have high blood pressure. The editorial concludes that “the study still strongly suggests that carvedilol is at least as safe as propranolol…. I am in complete agreement with the authors in suggesting that carvedilol is likely to represent the best NSBB in the treatment of portal hypertension regardless of the clinical scenario, including prevention of decompensation, ascites, first bleeding, or recurrent bleeding.” The author notes that the “recent Baveno VII recommendations declare carvedilol as the preferred NSBB, and support its use in all compensated patients with direct (HVPG ≥10 mm Hg) or indirect signs of clinically significant portal hypertension.”(J Hepatol. 2022; 76: 959-974. Baveno VII: renewing consensus in portal hypertension)

My take: In adults, Carvediol is the best NSBB for portal hypertension. In children, who may be more prone to hypotension, more data is needed.

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Juan-Les-Pins, France