Children rarely die early after a first variceal bleed, but cause and centre matter

Design

International multicentre retrospective cohort

Population

345 children after a first variceal haemorrhage at 44 centres

Primary outcome

Overall survival, survival with native liver, six-week mortality

Effect

Six-week mortality 4.1%; higher at low-volume centres; worse in cirrhosis and biliary atresia

An international study gathered outcomes for 345 children after a first variceal haemorrhage at 44 centres, grouped by volume and complexity of portal hypertension care.

Six-week mortality was 4.1% overall and 1.4% in children not admitted — low compared with adults. Survival, and survival with the native liver, were high in portal vein thrombosis and other non-cirrhotic causes and significantly lower in biliary atresia and cirrhosis. Worse outcomes were also seen with decompensation, after sclerotherapy, and where no endoscopic treatment was given. Six-week mortality was higher at low-volume than at high-volume centres.

The data are observational, and treatment choices reflect disease severity. But the results support managing children with portal hypertension in experienced centres and treating extrahepatic portal vein obstruction — common in Indian paediatric practice — as a condition with a good outlook when bleeding is managed well.

• Identify the cause of portal hypertension in a child who bleeds; outlook differs widely by diagnosis.
• Expect better outcomes in portal vein thrombosis than in cirrhosis or biliary atresia.
• Consider early referral to an experienced paediatric hepatology centre after a first bleed.
• Outcomes were worse after sclerotherapy; band ligation is preferred where feasible in children.

Why it matters

It gives families and clinicians a realistic, diagnosis-specific picture after a frightening first bleed.

Don't overread it

Associations with sclerotherapy and centre type may reflect case mix rather than treatment effect.

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