Introduction
Variceal bleeding is often a life-threatening clinical situation in infants and children.1 The experience of the "endoscopic community" in pediatric patients is limited, but during recent years, increased skills of the endoscopists and technological improvements led to standardization of pediatric endoscopy and development of specialized paediatric endoscopy unit.2 Optimal treatment of esophageal variceal bleeding is still controversialmeeting market demands.
Endoscopic variceal sclero-therapy (EVS) and surgical procedures are preferred modalities and have been shown to be effective in more than 90% of patients with active variceal bleeding but it is associated with various complications.3 EVS is an effective treatment for bleeding esophageal varices, however, EVS is associated with substantial complications including retrosternal pain, fever, sepsis, transient dysphagia and occasionally pleural effusion. Mucosal ulcerations at the site of injection are observed in 70-80% of the patients, and this is the cause of serious complications like rebleeding (up to 20%), esophageal stricture and perforation. 4,5 EVS is still not well defined in children with portal hypertension due to liver disease and here we tried to study some factors affecting benefits and outcome of this procedure.

Patients and Methods:

All children (n=49) who presented with variceal bleeding due to liver disease, were included in this study for 3 years.  The diagnosis of liver disease and cirrhosis was made and based on clinical, biochemical and radiological features; stages of cirrhosis based on Child-Turcotte-Pugh (CTP).⁶ Liver biopsy was done for all cases. In cases with acute variceal bleed, endoscopy was done after proper resuscitation. Varices were graded, according to Baveno V. guidelines.⁷ Varices were of grade III or IV in all patients at the start of endoscopic treatment. Two children were actively bleeding before the endoscopic procedure, which was successfully controlled by EVS. EVS was done by using forward viewing flexible video endoscope under conscious sedation (propofol), children underwent endoscopic injection with 1% ethanolamine maleate for 3 years period. All children continued to receive the therapy by repeated intra and extravariceal endoscopic injections, and not exceeding  8cm for each patient at intervals of weeks to months between sessions. They all received regular propranolol medication since they had been diagnosed (2 mg/Kg). Follow up endoscopy was done at 3-4 weeks and there after every 3-6 months or when patient developed upper gastrointestinal rebleeding.

We studied etiology of liver disease, duration of the disease, number of sclerotherapy sittings and propranolol dosage, all in relation to good outcome (grade I, II) by suitable statistical analysis.  

Statistical analysis: Continuous data are expressed as mean ± SD, unless specified otherwise. Descriptive statistics (number and percentages) were used to describe discrete data. The Statistical Package for Social Sciences (version 17.0; SPSS, Inc., Chicago, IL, United States) was used, and P < 0.05 was regarded as significant

Results:

49 children, had totally 141 injections, and were followed up regularly by upper GI endoscopy. The most common etiology was CHF (no=11), AIH (no=9), WD (no= 8) followed by BCS (no= 7) and other miscellaneous (no=14).   At the end of this follow up period, 25 out of 49 experienced hypertensive gastropathy (51.02%), 4 children had fundal gastric varices and 2 had gastric extensions. The good outcome (grade I, II) was in 19 out of 49 (38.78 %), 18/19 child had received 2mg/kg propranolol, 10 out 19 (52.63%) were in child B classification category, 17 children received 2-10 sitting to reach grade I and II. and the duration of injection sittings of 13/19 (68.42%) was just one year. 10/19(52.63%) children were above 10 years old age at the end of sclerotherapy and 11/19 (57.89%) of children diagnosed for 5 years before treating. Variceal eradication was achieved in all children in mean 2.8 sessions (range 2-4). Complete disappearance of varices was achieved in 10 patients while 3 patients had grade I varices. No complications observed in all patients related to sclerotherapy at time of treatment and no other major complications were noted during follow up (mean= 6.7, range=2-11 months). Good outcome correlated significantly to etiology, child classification, years of diagnosis before treatment, period since first sitting and number of sittings.  

Table. 1: Demographic data and outcome

Number of Outcome Grade (I-IV)	No. of sittings	First sitting (months)	Years of Dx	Child's class.	C/P	Etiology	Sex	Age/Yr
I        = 1 II       = 4 I, II    = 14 III      = 3 II, III = 18 III, IV = 9	2 - 24 (6.30 ± 4.58)	2 - 40 (13.96 ± 18.83)	2- 13 (5.28 ± 2.33)	A =18 B =15 C =16	H = 34 M = 3 H, M = 12	CHF =11 AIH = 9 WD = 8 BCS = 7	M = 30 F  = 19	2 - 17 (10.74 ± 4.17)

*Significant = < 0.05

Dx   = Diagnosis

CHF= Congenital hepatic fibrosis

AIH = Autoimmune hepatitis

BCS= Bud Chiari disease

WD = Wilson's Disease

H     = hematemesis

M    = Melena

Table.2: Demographic data in relation to good outcome

Outcome grade	No. of sittings M±SD	First sitting (Mo) M±SD	Years of Dx.  (Yr) M±SD	Etiology
I     = 1 II    = 4 I, II = 14	2-24 (6.00 ± 4.31)	4 -29 (17.53± 27.03)	3 -5 (4.74± 2.16)	AIH  = 5 WD  = 4 BCS = 3 Unknown =3	Results
-	0.077 *	0.027 *	0.036 *	0.022*	P value

*Significant = < 0.05

Dx    = Diagnosis

AIH  = autoimmune hepatitis

BCS = Bud Chiari disease

WD  = Wilson’s Disease

Discussion: Bleeding of esophageal varices is the main cause of morbidity and mortality in children with portal hypertension due to liver disease.² In the study group, variceal eradication was achieved in all patients in mean 2.8 sessions (range = 2-4). Complete disappearance of varices was achieved in 10 patients while 3 patients had grade I varices. In concordance with the present results, endoscopic injection sclerotherapy has been described with favorable results as both primary ^8-10 and secondary prophylaxis of variceal hemorrhage in children and adolescents with cirrhosis.^11-12 Other study reported that endoscopy in children remains a very safe procedure, although a more detailed understanding of risk factors and ideal training and practice organization is lacking.⁷ In the pediatric population, EVS and esophageal variceal banding (EVL) are considered the methods of choice in the treatment of esophageal variceal hemorrhage and prevention of rebleeding.¹³ Sclerotherapy being favorable and reserved for small children in whom it is not anatomically possible to use the equipment for EVL.¹⁴ One study on biliary atresia, the patients with grade 2 or 3 varices received sclerotherapy every 2 to 4 weeks until eradication, the efficiency of this sclerotherapy protocol among the failed portoenterostomy patients was poor, despite initially successful eradication, varices eventually reappeared in all ¹⁵ and that may be due to difference in age and duration of varices. Also, other reports were in concordance of our study where the mean time needed for varices eradication was 3 to 6 months.¹⁶ At the end of the present study and follow up period, 25 out of 49 had hypertensive gastropathy (51.02%), 4 patients had fundal gastric varices and 2 patients had gastric extensions. In one study, no significant hypertensive gastropathy was encountered. Despite similar sclerotherapy protocol, variceal hemorrhage was significantly more frequent after a failed portoenterostomy than in patients who developed varices several years after an initially successful portoenterostomy. This is not unexpected in the light that after failed portoenterostomy children display rapidly progressive cholestatic liver failure and cirrhosis.¹⁵ Stiegmann and Goff developed EVL as an alternative to endoscopic sclerotherapy However, there was no difference in variceal eradication rate between EVS and EVL which developed recently.^17,13 We used Propofol for sedation and no complications noted. Other authors reported that sedation of children during endoscopy might need further evaluation and standardization, to reduce the rate of specific complications.¹⁸ Some authors use general anaesthesia to optimize examination and minimize the risk of blood aspiration.^19,20  

Conclusions: Endoscopic sclerotherapy is a safe and effective treatment for esophageal varices in children due to liver disease. Good outcome was correlated significantly with etiology, child classification, years of diagnosis before treatment and number of sittings. All these factors and Long-term outcome had to be studied on large cohort and extended research.

Conflicts of Interest:

No conflicts of interest

Acknowledgement:

The authors would like to thank all colleges, at Menoufiyia University, for helping to develop this article manuscript and providing a valuable actual review.

Fundings:

This study was funded by the National Liver Institute, Menoufiya University, without any particular role in the study design, recruitment of individuals, data analysis or the writing of the manuscript.