Original article
Clinical endoscopy
Prevalence, nature, and predictors of colonic changes in children with extrahepatic portal vein obstruction

https://doi.org/10.1016/j.gie.2019.11.042Get rights and content

Background and Aims

The medical literature on colonic changes in children with extrahepatic portal venous obstruction (EHPVO) is limited. We evaluated EHPVO children for prevalence, nature, and relation of colonic changes with disease duration, extent of splenoportal axis (SPA) thrombosis, portal hypertensive gastropathy (PHG), and esophageal varices (EVs). The correlation between histologic and endoscopic changes was studied.

Methods

Subjects were evaluated by colonoscopy with ileoscopy and biopsy sampling, clinico-laboratory profiles, and SPA imaging. Colonic changes were classified as varices (rectal/colonic) and portal hypertensive colopathy (PHC; colitis-like or vascular lesions). Morphometric analysis of colonic biopsy specimens was performed.

Results

Fifty-four children (median age, 12 years [range, 8-15]; hematochezia in 9 [16.6%]) were evaluated. Rectal and colonic varices were seen in 51 (94%) and 2 (3.7%) cases, respectively. Seventy-five percent of patients had PHC, and colitis-like lesions were more common than vascular lesions (36/40 vs 23/40; P = .001). Colopathy changes were pancolonic in 52.5%, left-sided in 42.5%, and right-sided in 5% of cases. Sixteen percent of patients (8/49) had ileal changes. Children with PHC had PHG more often (90% vs 57%; P = .01), more endotherapy sessions (mean 6 [range, 4-8] vs 2 [range, 1-4]; P = .03), and large EVs less often (12.5% vs 43%; P = .02) than those without colopathy. The extent of SPA thrombosis was similar in patients with and without PHC. The number of capillaries per crypt was higher in EHPVO than in control subjects. Morphometric changes had no correlation with endoscopy.

Conclusions

Most EHPVO children had colonic changes, and 16% had ileopathy. “Colitis-like” changes and left-side involvement were more common. Patients with PHG and eradicated EVs had a higher risk of PHC.

Section snippets

Methods

Children (≤18 years) with EHPVO were prospectively enrolled either at diagnosis or during follow-up. Diagnosis of EHPVO was based on consensus guidelines of the Asian Pacific Association for the Study of Liver.12 Children who were on beta-blockers, had previous surgery for PHT (portosystemic shunt, splenectomy, or devascularization), had coexisting chronic liver disease, or who refused to participate were excluded. Disease duration was calculated from the time of first detection of splenomegaly

Results

Fifty-four EHPVO children (41 boys; median age at enrollment, 12 years [IQR, 8-15]; median duration of symptoms before diagnosis, 5 years [IQR, 3.5-7.9]) were evaluated. Most children (n = 46; 85%) had presented with hematemesis and the remaining with splenomegaly. Fifty-two children were on endotherapy (EVL or EST); 46 patients were post variceal bleed and 6 were on prophylactic EVL. Most patients (93%; n = 50) were enrolled in follow-up while on endotherapy, and only 4 children were enrolled

Discussion

We found RVs in 94% and PHC in 74% of our EHPVO children. Colonic varices were uncommon (3.7%), and 16% had ileal changes. In patients with colopathy, colitis-like changes were more common than vascular lesions, and the left side of the colon was involved more often than the right side. PHC patients were more likely to have PHG and increased number of endotherapy sessions (EVL/EST) with eradicated varices. We have described a new finding of punched-out ulcers in 6 patients (15%). Bleeding per

References (41)

  • M.E.P. Gonçalves et al.

    Prophylactic sclerotherapy in children with esophageal varices: long-term results of a controlled prospective randomized trial

    J Pediatr Surg

    (2000)
  • T. Iwao et al.

    Portal hypertensive gastropathy in patients with cirrhosis

    Gastroenterology

    (1992)
  • S.K. Yachha et al.

    Gastrointestinal bleeding in children

    J Gastroenterol Hepatol

    (1996)
  • U. Poddar et al.

    Etiological spectrum of esophageal varices due to portal hypertension in Indian children: Is it different from the West?

    J Gastroenterol Hepatol

    (2008)
  • N.K. Arora et al.

    Portal hypertension in North Indian children

    Indian J Pediatr

    (1998)
  • U. Poddar et al.

    Frequency of gastropathy and gastric varices in children with extrahepatic portal venous obstruction treated with sclerotherapy

    J Gastroenterol Hepatol

    (2004)
  • S.P. Misra et al.

    Colonic changes in patients with extra hepatic portal vein obstrcution

    Endoscopy

    (2005)
  • Y. Chawla et al.

    Anorectal varices—their frequency in cirrhotic and noncirrhotic portal hypertension

    Gut

    (1991)
  • M.K. Goenka et al.

    Rectosigmoid varices and other mucosal changes in patients with portal hypertension

    Am J Gastroenterol

    (1991)
  • N.D. Heaton et al.

    Incidence of haemorrhoids and anorectal varices in children with portal hypertension

    Br J Surg

    (1993)
  • DISCLOSURE: All authors disclosed no financial relationships.

    View full text