A child's first variceal bleed: low early mortality, but outcome depends on the diagnosis

Design

International multicentre retrospective cohort

Population

345 children after a first variceal haemorrhage at 44 centres

Primary outcome

Overall survival and survival with native liver

Effect

6-week mortality 4.1% (1.4% if not hospitalised); worse in cirrhosis and biliary atresia

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

Six-week mortality was 4.1% overall and 1.4% in children not admitted to hospital. Overall survival and survival with native liver were high in portal vein thrombosis and other non-cirrhotic causes, and significantly lower in biliary atresia and cirrhosis. Survival with native liver was worse with decompensation, with biliary atresia and poor bile flow, after sclerotherapy, and when no endoscopic therapy was given. Six-week mortality was higher in low-volume than high-volume centres.

For India, where extrahepatic portal vein obstruction is a common cause of variceal bleeding in children, the finding that these children do well is reassuring. Children with cirrhosis or biliary atresia, and those who bleed while decompensated, need early referral to a centre with paediatric hepatology and transplant access. The centre-level comparison is observational and may reflect case mix.

• Identify the cause of portal hypertension in any child after a first variceal bleed.
• Expect good outcomes in portal vein thrombosis; prioritise referral for cirrhosis and biliary atresia.
• Consider band ligation rather than sclerotherapy where the child's size allows.
• Refer children who bleed with ascites or decompensation to a high-volume centre.

Why it matters

Primary prophylaxis in children is debated precisely because the risk after a first bleed was poorly known.

Don't overread it

Observational; the sclerotherapy and centre-volume associations may reflect which children received them.

The statistics, in plain English

A 4.1% six-week mortality is much lower than in adults. Comparisons between centre types used a causal model but remain observational, so sicker children at some centres could explain part of the difference.

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