Children's first variceal bleed: low early mortality, outcomes vary by cause

Design

International multicentre retrospective cohort

Population

345 children after a first variceal haemorrhage at 44 centres

Primary outcome

Overall survival, survival with native liver, and 6-week mortality

Effect

6-week mortality 4.1% overall; higher in low-volume vs high-volume centres (P = 0.010)

This international study collected data from 44 centres on 345 children after their first variceal haemorrhage, and grouped centres by volume and complexity of portal hypertension care.

Overall six-week mortality was 4.1%, and 1.4% in children not needing hospital admission, which is lower than reported in adults. Overall survival and survival with the native liver were high in portal vein thrombosis and other non-cirrhotic causes, and significantly worse in biliary atresia and cirrhosis. Decompensated disease, poor bile flow in biliary atresia, sclerotherapy and absence of endoscopic intervention were associated with worse native-liver survival. Six-week mortality was higher in low-volume centres than high-volume ones.

These findings inform the ongoing debate on primary prophylaxis in children: risk depends heavily on the underlying diagnosis, and where a child is treated may matter.

• Stratify children with portal hypertension by underlying cause when discussing bleeding risk.
• Consider early referral of children with biliary atresia or cirrhosis to a high-volume centre.
• Consider band ligation where feasible; sclerotherapy was associated with worse outcomes.
• Expect better outcomes in extrahepatic portal vein obstruction, common in Indian practice.

Why it matters

Paediatric decisions have relied on adult data that overstate early mortality.

Don't overread it

This does not settle whether primary prophylaxis benefits children.

The statistics, in plain English

This is observational, so the link between sclerotherapy and worse outcomes may reflect which children received it. The centre comparison used causal-inference methods but cannot remove all differences in case mix.

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