Management of Portal Hypertension in Children

University of California, San Francisco, San Francisco, CA 94143-0136, USA.
Current Gastroenterology Reports 10/2010; 13(1):10-6. DOI: 10.1007/s11894-010-0151-y
Source: PubMed

ABSTRACT Management of portal hypertension in children has evolved over the past several decades. Portal hypertension can result from intrahepatic or extrahepatic causes. Management should be tailored to the child based on the etiology of the portal hypertension and on the functionality of the liver. The most serious complication of portal hypertension is gastroesophageal variceal bleeding, which has a mortality of up to 30%. Initial treatment of bleeding focuses on stabilizing the patient. Further treatment measures may include endoscopic, medical, or surgical interventions as appropriate for the child, depending on the cause of the portal hypertension. β-Blockers have not been proven to effectively prevent primary or secondary variceal bleeding in children. Sclerotherapy and variceal band ligation can be used to stop active bleeding and can prevent bleeding from occurring. Transjugular intrahepatic portosystemic shunts and surgical shunts may be reserved for those who are not candidates for transplant or have refractory bleeding despite medical or endoscopic treatment.

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    ABSTRACT: The transjugular intrahepatic portosystemic shunt (TIPS) is effective for treating complications of portal hypertension in cirrhotic adults but the experience in children is limited. To retrospectively review the safety and efficacy of expanded polytetrafluoroethylene (ePTFE)-covered TIPS in children with acute or recurrent gastrointestinal bleeding. We reviewed the medical records of children who received implants of 10-mm-diameter PTFE-covered endoprostheses for acute or recurring upper gastrointestinal bleeding caused by medically or endoscopically uncontrollable varices. The recurrence of upper gastrointestinal bleeding, associated complications and permeability were assessed with Doppler sonography sequentially or up to transplantation. In all children (n = 12; mean age 9 years; mean weight 30 kg) a single endoprosthesis was implanted with no associated mortality. The mean initial transhepatic gradient was 15 mmHg (range 3-21 mmHg), dropping to 7 mmHg (range 1-12 mmHg) after TIPS. Immediate complications were mild encephalopathy (n = 1) and acute occlusion of the TIPS (n = 1). Stenosis of the TIPS was observed in two children, at 9 months and 54 months follow-up, and thrombosis was observed in two children, at 7 months and 12 months follow-up. All four stenoses/occlusions were resolved with coaxial endoprostheses. The safety profile and efficacy of expanded polytetrafluoroethylene (ePTFE)-covered TIPS were satisfactory in this small series of children with acute or recurrent gastrointestinal bleeding.
    Pediatric Radiology 11/2014; 45(3). DOI:10.1007/s00247-014-3181-z · 1.65 Impact Factor
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    ABSTRACT: Objective To retrospectively analyze the safety and efficacy of transjugular intrahepatic portosystemic shunting (TIPS) using covered stents in children. Material and methods We present 6 children (mean age, 10.6 years; mean weight, 33.5 kg) who underwent TIPS with 8 mm diameter Viatorr® covered stents for acute (n=4) or recurrent (n=2) upper digestive bleeding that could not be controlled by endoscopic measures. Five of the children had cirrhosis and the other had portal vein thrombosis with cavernous transformation. We analyzed the relapse of upper digestive bleeding, the complications that appeared, and the patency of the TIPS shunt on sequential Doppler ultrasonography or until transplantation. Results A single stent was implanted in a single session in each child; none of the children died. The mean transhepatic gradient decreased from 16 mmHg (range: 12-21 mmHg) before the procedure to 9 mmHg (range: 1-15 mmHg) after TIPS. One patient developed mild encephalopathy, and the girl who had portal vein thrombosis with cavernous transformation developed an acute occlusion of the TIPS that resolved after the implantation of a coaxial stent. Three children received transplants (7, 9, and 10 months after the procedure, respectively), and the patency of the TIPS was confirmed at transplantation. In the three remaining children, patency was confirmed with Doppler ultrasonography 1, 3, and 5 months after implantation. None of the children had new episodes of upper digestive bleeding during follow-up after implantation (mean: 8.1 months). Conclusion Our results indicate that TIPS with 8 mm diameter Viatorr® covered stents can be safe and efficacious for the treatment of upper digestive bleeding due to gastroesophageal varices in cirrhotic children; our findings need to be corroborated in larger series.
    Radiología 08/2014; 56(4):339–345. DOI:10.1016/j.rx.2012.01.010
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    ABSTRACT: The aim of the present study was to investigate the effects of octreotide treatment on hepatic heme oxygenase‑1 (HO‑1) expression, together with the influence of altered hepatic HO‑1 expression levels on hepatic function and fibrosis in bile duct‑ligated rats. The rats were divided randomly into sham, cirrhotic, cobalt protoporphyrin and octreotide treatment groups. The expression levels of hepatic HO‑1 mRNA were measured by reverse‑transcription polymerase chain reaction, while the protein expression was determined by western blotting and immunohistochemical analysis. Hematoxylin and eosin, and Van Gieson's staining, along with determination of the hydroxyproline content in the liver, were performed to determine the degree of liver fibrosis. The serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL) and carboxyhemoglobin (COHb) in arterial blood, and the mean arterial pressure and portal vein pressure were also measured. As compared with the sham group, hepatic HO‑1 mRNA and protein expression levels, serum levels of ALT, AST and TBIL, COHb in arterial blood, hydroxyproline and collagen type I content were all significantly increased in the cirrhotic group. As compared with the cirrhotic group, the octreotide‑treated group exhibited significantly reduced hepatic HO‑1 expression levels, serum levels of ALT, AST and TBIL, COHb in arterial blood and the extent of hepatic fibrosis, whereas the cobalt protoporphyrin group exhibited significantly increased hepatic HO‑1 expression levels, as well as aggravated hepatic function and fibrosis (P<0.05). In conclusion, octreotide inhibited hepatic HO‑1 overexpression in cirrhotic rats, reduced hepatic HO‑1 expression levels to relieve liver injury and attenuated liver fibrosis.
    Molecular Medicine Reports 10/2014; 11(1). DOI:10.3892/mmr.2014.2735 · 1.48 Impact Factor

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