Acute bleeding

Initial management should be according to an institutional protocol and usually involves treatment with octreotide and antibiotics. Therapeutic endoscopy should be performed under general anesthetic, as soon as possible once the patient is hemodynamically stable. ESGE‐ESPGHAN guidance is that endoscopy should occur within 12 hours of an acute upper gastrointestinal bleed if the child requires ongoing circulatory support, if they have known esophageal varices, or if a large hematemesis or melena has occurred [9]. If bleeding continues, the procedure should be carried out immediately. If a bleeding varix is identified, this should be treated first. Where no bleeding point is found, treatment should usually be commenced, so long as no other potential site for bleeding exists and varices are high risk.

Endoscopic sclerotherapy is well established and the choice of sclerosant appears unimportant, with 5% ethanolamine oleate used widely. The injection is carried out via the endoscopic operating channel using single‐use injectors. Endoscopes with working channels down to 2.2 mm may be used. Injections are started just above the gastroesophageal junction and may be intra‐ or paravariceal. All varices at this level should be treated, with 1–3 mL of sclerosant being used per injection, then repeated if necessary to all varices 3–5 cm caudally. No more than 10–15 mL of sclerosant should be used per session, depending on patient size. Varices more than 5 cm from the gastroesophageal junction should not be treated unless actively bleeding.

Endoscopic ultrasound (EUS) may help to target sclerotherapy with histoacryl glue in the gastric fundus (Figure 31.2). It affords a real‐time image of the gastrointestinal wall and feeding blood vessels, treatment of which may reduce variceal recurrence. After sclerotherapy, Doppler may be used to confirm variceal ablation.

Sclerotherapy is very effective, with control of acute bleeding in 90% of cases. Complications are more likely following emergency sclerotherapy, occurring in approximately 18% [10], and include esophageal ulceration, bleeding, mediastinitis, esophageal perforation, chylothorax, pneumothorax, and stricture formation. There is a procedural mortality of approximately 1%.

Band ligation (EVL) was first reported in humans in 1989. In this technique, a hollow cylinder with prestretched rubber rings is attached to the front of an endoscope. The variceal column is directly sucked into the hollow cylinder and the band is released around the base of the varix (Figure 31.3). Strangulation of the varix stops acute bleeding. Over the next few days, ischemic necrosis of the mucosa and submucosa develops and the rings are sloughed, leaving shallow mucosal ulceration. Epithelialization occurs within 2–3 weeks and the submucosal vascular layers are replaced by maturing scar tissue by eight weeks [11].

An initial control endoscopy is carried out to recognize bleeding points and document the distance to the gastroesophageal junction to prevent inadvertent gastric banding. The apparatus is loaded onto the endoscope, ensuring a secure fit, and then repassed as far as the gastroesophageal junction. The bander is maneuvered to the most distal variceal column and suction applied (see Figure 31.3). When the varix fills the cylinder, the tripwire is pulled and the endoscope pulled back. Care must be taken, especially in small children, that the esophageal wall is not aspirated into the cylinder. Subsequent bands are applied in a proximal direction to variceal columns in the lower 5–6 cm of the esophagus. Up to 10 bands can be used per session but we usually restrict this to four, as more is often uncomfortable. Some manufacturers insert a colured band to remind the operator when a single band remains. EVL is much better tolerated than sclerotherapy [12]; 10–15% of children complain of transient retrosternal pain but esophageal stricture has not been reported in the pediatric literature.

Where feasible, EVL is the preferred technique for managing acute bleeding. A major advantage is that once the bleeding point is ligated, bleeding control with improved visibility is immediate. EVL can be used in children <10 kg so long as the loaded bander can be passed through the cricopharynx. However, it is not possible to pass the banding equipment in all children, so sclerotherapy should continue to be available.

Following endoscopic therapy, patients should fast for at least two hours and solid feeding should be withheld until liquids are tolerated. Sucralfate should be given for five days as this appears to decrease the risk of early rebleeding [13]. Proton pump inhibitors and antibiotics probably do not affect rebleeding rate. Clipping may be used occasionally but is not routinely recommended [14]. Post‐Kasai variceal banding is reported [15].

Hemospray®

Hemostatic spray is a simple technique in which powder is sprayed through the endoscope onto actively bleeding lesions where it forms a mechanical hemostatic barrier. This has been effective in the treatment of diffuse portal hypertensive gastropathy. It has also been applied directly to actively bleeding varices with good short‐term effect. While not a definitive treatment, this appears safe and easy to administer, particularly if experienced interventional endoscopists are not immediately available [16] (see Chapter 30).

Self‐expanding metal stents

This technique has recently been described in adult practice for resistant bleeding. The stent is deployed in the lower esophagus with or without direct endoscopic visualization and provides immediate hemostasis while allowing oral intake [17]. The stent can be left in place for 14 days, to facilitate definitive treatment, and subsequently removed endoscopically. There is no reported pediatric experience with the technique yet, but it would appear to be a useful addition to our therapeutic options.