Prophylactic endoscopic sclerotherapy of large esophagogastric varices in infants with biliary atresia

Background: Esophageal varices-related GI bleeding occurs frequently and early in life in children with biliary atresia and it may be life threatening. Objective: We report the results of prophylactic sclerotherapy in 13 infants with biliary atresia and large varices. Patients: Mean age was 13 months, mean weight was 8.2 kg, mean total serum bilirubin was 258 μmol/L, and mean prothrombin time was 78%. Esophageal varices were grade III (11 patients) or II (2 patients), with red signs in all infants and gastric varices in 12. None had GI bleeding. Intervention: Sclerotherapy was performed with the patient under continuous intravenous octreotide therapy in 7 infants. Results: In 8 children a complete or almost complete eradication of varices was obtained; none of these children bled later, 4 underwent liver transplantation, 3 are alive without liver transplantation, and 1 died of sepsis after 9 months awaiting liver transplantation. In 4 children a partial eradication was obtained and liver transplantation was performed. None of these children bled. One other child bled to death after 2 sessions of sclerotherapy. Limitations: Four ulcers and 2 stenoses occurred in 6 children with no octreotide versus no ulcer and 1 stenosis in 7 children receiving octreotide. Conclusion: These results (1) indicate that primary prevention of GI bleeding by sclerotherapy of esophageal varices is technically feasible and fairly effective in infants with biliary atresia and large varices, even in those with end-stage liver disease, (2) suggest that decreasing the risk of bleeding may allow liver transplantation under better conditions, and (3) further suggest that octreotide associated with sclerotherapy lowers the rate of complications.