Journal of Pediatric Gastroenterology & Nutrition:
Original Articles: Hepatology and Nutrition
Portal Gastropathy and Duodenopathy in Children With Extrahepatic and Intrahepatic Portal Hypertension: Endoscopic Diagnosis and Histologic Scoring
Aydoğan, Ayşen*; Güllüoğlu, Mine†; Önder, Semen Yeşil†; Gökçe, Selim*; Çeltik, Coşkun*; Durmaz, Özlem*
*Departments of Pediatric Gastroentrology, Hepatology, and Nutrition, Turkey
†Pathology, Istanbul University Faculty of Medicine, Istanbul, Turkey.
Received 24 November, 2010
Accepted 25 January, 2011
Address correspondence and reprint requests to Özlem Durmaz, MD, Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Istanbul University School of Medicine, Istanbul, Turkey (e-mail: firstname.lastname@example.org).
The authors report no conflicts of interest.
Objectives: The aim of the study was to determine the frequency of portal gastropathy (PG) and duodenopathy (PD) in children, to document the correlation of various clinical and laboratory parameters associated with portal hypertensive gastroduodenal lesions, to compare the endoscopic portal hypertensive lesions with different histologic findings, and to evaluate the use of a possible histologic scoring system.
Methods: All children undergoing endoscopic investigation for portal hypertension (PH) between January 2006 and November 2007 were analysed retrospectively. Clinical and demographical data and endoscopic and histologic findings were recorded. Histologic findings suggestive of PG and PD (capillary dilation, increased numbers of capillaries, histologic bleeding, and edema) were scored.
Results: Of 51 consecutive children (29 boys, mean age 10.1± 3.6 years [range 2.5–15.8 years]), 28 were cirrhotic. PG was diagnosed in 58.8% endoscopically. Children with cirrhotic PH had the highest rate of PG (64.3%), whereas those with extrahepatic or intrahepatic noncirrhotic PH were alike (50% and 54.5%, respectively). Baveno PG scores were higher in children with cirrhosis with higher Child-Pugh scores. Capillary dilation was the only histologic finding showing significant association with the endoscopic diagnosis. Only 9% had PD on endoscopy. None of the histologic findings correlated with endoscopic diagnosis of PD.
Conclusions: PG and PD are seen in children with extrahepatic and intrahepatic PH at rates similar to those reported in adult studies. Baveno PG scores increased in parallel with Child-Pugh class in children with cirrhosis. Capillary dilation was the only histologic finding showing significant association with the endoscopic diagnosis of PG in this study.
Gastrointestinal mucosal abnormalities have long been recognized in association with portal hypertension (PH). Portal gastropathy (PG) is defined as a condition in which there are macroscopic changes of the gastric mucosa associated with mucosal and submucosal vascular ectasia, and dilation without significant histologic inflammatory changes in appropriate clinical settings (1,2). These mucosal lesions include the presence of a mucosal mosaic pattern, cherry-red spots, and/or black-brown spots (1). The clinical importance of PG is the risk of acute life-threatening bleeding along with chronic blood loss. Pediatric data on the frequency of these gastroduodenal lesions are scarce and there are no widely accepted criteria for diagnosis of gastroduodenal pathologies associated with PH in the pediatric age group.
The aim of this retrospective study was to assess the correlation of various clinical and laboratory parameters associated with PH and liver dysfunction, to determine the frequency of portal hypertensive gastroduodenal lesions, to compare the endoscopic markers with different histologic findings, and to evaluate the use of a possible histologic scoring system.
PATIENTS AND METHODS
All patients younger than 18 years undergoing endoscopic investigation for PH during a 1-year period between January 2006 and November 2007 were analysed. Demographic data and clinical and endoscopic findings were extracted from the case records and endoscopic reports. PH was defined according to physical, laboratory, and endoscopic findings. Underlying liver disease, etiology of PH, duration of the disease and PH, treatment protocols, gastrointestinal bleeding history, physical findings (hepatomegaly, splenomegaly, ascites, and cutaneous findings of chronic liver disease, such as palmar erythema, clubbing, and telangiectasia) and the laboratory data (anemia, leucopenia, thrombocytopenia, prothrombine time (PT) prolongation unresponsive to vitamin K injection, hypoalbuminemia, and hyperbilirubinemia) were included.
The levels of blood components and biochemical indices were evaluated according to the references for age (3). The PT prolongation was defined as an increased prothrombin time of at least 4 seconds above the laboratory reference range. Severity of the liver disease was graded according to Pediatric End Stage Liver Disease (PELD) Score and Child-Pugh scoring system in children with cirrhosis (4,5). Endoscopic portal hypertensive gastric mucosal lesions were scored according to the Baveno classification (1). Esophageal and gastric varices were graded according to previously established criteria (6,7).
Upper gastrointestinal endoscopy and histopathological studies were performed by 1 of the 4 pediatric endoscopists and the same pathologist. The biopsy specimens (at least 3 antrum, 3 fundus, and 4 duodenum) were taken with biopsy forceps of 1.8 or 2.3 mm in diameter. One antrum biopsy and 1 fundus biopsy were evaluated with the rapid urease test. Specimens were fixed in Holland solution and stained with haematoxylin and eosin. Gastric specimens were additionally stained with modified Giemsa to investigate Helicobacter pylori. An Olympus BX51model light microscope was used (Olympus, Tokyo, Japan).
Histologic findings suggestive of PG and duodenopathy (PD) were scored out of 4 positive points. These included capillary dilation, increased numbers of capillaries, histologic bleeding and edema in gastric and duodenal biopsies, and inflammation, foveolar epithelium hyperplasia, and H pylori in gastric biopsies. PG and PD scores were calculated.
The χ2 test was used for the comparison between categorical data and, when needed, the Fisher exact test for small groups. The normal distribution analysis was done for the numerical data, and appropriate parametric and nonparametric tests (Mann-Whitney U and Kruskal-Wallis H tests) were chosen. P < 0.05 was considered significant. The study was approved by the Istanbul University ethics committee. Written informed consent was signed by the parents.
Fifty-one consecutive children (29 boys, mean age 10.1 ± 3.6 years [range 2.5–15.8 years]) were included in the study. Table 1 summarizes the endoscopic findings in relation to the etiology of PH. The median time between the diagnosis of PH and endoscopy was 5.3 ± 3.2 years (range 1 month–14.5 years). Clinical features are shown in Table 2.
PG was found in 30 (58.8%) patients. Children with cirrhotic PH had the highest rate of PG (64.3%), whereas those with extrahepatic or intrahepatic noncirrhotic PH were similar (50% and 54.5%, respectively); however, the relation between the etiology of PH and PG and PD was not significant (P = 0.38 and P = 0.64, respectively).
All of the patients with PG had scores ≤3 (Table 3). Among them, mucosal mosaic pattern was found in almost all of the patients with cirrhosis (P = 0.041). One patient had gastric antral vascular ectasia (GAVE). Portal hypertensive duodenal lesions (varices at the second portion, isolated red markings, marked vascularisation at bulbus, sessile polyp, and multiple polyps, respectively) were found in 5 patients (9%).
Among 28 patients with chronic liver disease, 18 had Child-Pugh A, 8 Child-Pugh B, and 2 Child-Pugh C cirrhosis. Baveno PG scores were higher in patients with cirrhosis with higher Child scores (P = 0.001) (Fig. 1). The relation between Child scores and PD was not significant (P = 0.53). There was no significant difference in incidence of PG and PD in relation to PELD scores (P = 0.39 and P = 0.53, respectively).
Esophageal varices were found in 46 patients (90%) (grade I, n = 22; grade II, n = 11; grade III, n = 13). Thirteen of them (25%) also had gastric varices (gastroesophageal [GOV] I and GOV II). Seven patients (28%) of 25 intrahepatic cirrhotic, 5 patients (50%) of 10 intrahepatic noncirrhotic PH, and 1 patient (9%) of 11 extrahepatic PH had cherry-red spots on their esophageal varices. No association was found between PG and PD and esophageal varices, number and grade of varices, and cherry-red spots on them. There was no significant difference in incidence of PG and PD in relation to gastric varices (P = 0.33 and P = 0.09, respectively).
Bleeding history was positive in 21 patients. Fifty-seven percent of them bled massively and needed transfusions. The remainder had milder bleeding incidents without transfusion requirement. The total number of bleeding episodes was <5 in most of the patients (12/21). The median number of bleeding episodes during the previous year was 1 (range 0–2). The median time period between endoscopy and the last bleeding episode was 26 weeks (range 0.14–364 weeks). Five episodes of upper gastrointestinal bleeding occurred in 3 patients during the study period. None bled from PG. The bleeding episodes were caused by duodenal ulcer in 1 patient and variceal hemorrhage in others. We did not encounter any iatrogenic bleeding episode in relation to endoscopic forceps biopsies. All of the patients except 1 responded to medical therapy with somatostatin analogs and histamine receptor blockers. We lost 1 patient who bled from esophageal varices and managed with Sengstaken-Blakemore tube for 2 days as a result of sepsis at the 10th day.
No association was found between PG and bleeding history. However, the relation between the bleeding history and PD was significant (P = 0.009). The total number of bleeding, bleeding number during the previous year, and the time period between endoscopy and the last bleeding episode were not significant in relation to PD and PG.
Fifteen patients had not received any treatment for PH. Another 15 patients had undergone 1 to 9 episodes of endoscopic variceal treatment, median 73 weeks (13–312 weeks), before endoscopy along with medical treatment (propranolol). The total number of endoscopic treatments was 56. Five patients had endoscopic band ligation, 2 had sclerotherapy, and 8 had the 2 modalities together. Four patients had surgery (1 splenectomy, 1 splenectomy + distal splenorenal shunt, 2 splenectomy + Siguira operation). The history of endoscopic treatment, the number of sessions, and the time period after the last session showed no correlation with the presence of PG and PD.
Endoscopic diagnosis of PG but not PD showed significant association with the cutaneous findings of chronic liver disease (P = 0.045). No association was found between PG and PD and age of the patient, hepatomegaly, splenomegaly, ascites, laboratory findings, duration and treatment modalities of PH, and presence of H pylori.
Capillary dilation was the only histologic finding showing significant association with the endoscopic diagnosis of PG (P = 0.042) (Fig. 2). None of the histologic findings correlated with endoscopic diagnosis of PD. The addition of scores for each histologic finding either for PG or PD did not make any difference.
Portal hypertensive gastrointestinal mucosal lesions are common complications of PH in children as they are in adults. The prevalence of PG and PD has been reported to be in the range of 4% to 98% and 8% to 69% in the adult population, respectively (2,8–10). Pediatric data on the frequency of PG are limited and vary between 40% and 64% (11–13). There are no published data about the incidence of PD in children. Duodenal polyp seems to be a newly described portal hypertensive duodenal lesion that has not been reported in adults. We found the rate of PG was 58%, similar to previous pediatric studies, and PD was 9%.
Generally, PG is thought to be more common in cirrhotic PH. In a multicenter study among 2720 consecutive adult patients (21% cirrhotic, 79% noncirrhotic) evaluated endoscopically, the rate of PG was found to be 63.3% in children with cirrhosis versus 16.9% in children without cirrhosis (14). In another, larger study, patients were studied for a 2-year period and PG was reported in 61% of children with cirrhosis, 54% of children without cirrhotic PH, and in 20% of children with extrahepatic portal vein obstruction (15). In a pediatric study, no association was found between PG and the cause of PH among 18 children with intrahepatic and 6 children with extrahepatic portal hypertension (13). In our population of 51 patients, children with cirrhotic PH had the highest rate of PG. Additionally, 2 significant findings were the relations between cutaneous findings of chronic liver disease and PG, and between mosaic pattern of gastric mucosa and cirrhosis, supporting the relation between cirrhosis and PG; however, the relation between the etiology of PH and PG and PD was not significant.
Several studies have noted that the likelihood of developing PG was dependent on the severity of liver disease (16–19), whereas the others have not (20–23). In a natural history study, a total of 222 patients with cirrhosis with a mild degree of PH were followed up with upper endoscopy every 12 months for 47 ± 28 months, and Child-Pugh class B or C was found to be associated with the progression from mild to severe PG (17). Similarly, we found that Baveno PG scores were higher in cirrhotics with higher Child-Pugh scores; however, there was no significant difference in incidence of PG and PD in relation to Child-Pugh class and PELD scores. This may be due to the paucity of Child-Pugh class C in our cirrhotic population.
There has been no consensus on the relation of presence and grade of esophageal and/or gastric varices with PG and PD. Some authors found positive correlations between the grade of esophageal varices and PG, whereas some failed to find any association (18–20,24). No correlation between the size of varices and PG in 22 children with PH was reported (11). There was no significant relation between gastric varices and PG in another pediatric study among 40 children with extrahepatic PH (12) similar to some adult studies (15,19). No relation between PD and esophageal (10,24,25) and gastric varices (25) was found. In agreement with these reports, we also failed to find any relation between PG and PD and the presence of esophageal and gastric varices, the size and the number of esophageal varices, and cherry-red spots on them.
Variceal eradication may exacerbate the development of PG. Claims of an association were supported by numerous studies (15,16,23,24). Two publications studying the children with extrahepatic PH during the period 1992 through 2002 emerged from India. PG increased in frequency after eradication of esophageal varices by endoscopic sclerotherapy from 12% to 41% among 163 children and from 24% to 51% among 186 children (26,27). The authors also described an increase in severity of PG. In another pediatric study including 100 consecutive children with cirrhotic and noncirrhotic PH prophylactic, sclerotherapy increased the risk of bleeding from PG (28). On the contrary, it was shown that changes in the severity of PG after endoscopic variceal sclerotherapy or ligation were reversible in adults (29). Similarly, PG developing after variceal eradication was often transitory and less severe (30). In the context of PD, some studies showed an association between variceal eradication and PD (31), whereas some others could not (24,25,32). In our study, no relation among the history of endoscopic treatment, the number of sessions, and the time period after the last session with PG and PD was found. Portal hypertensive gastrointestinal mucosal changes, however, are dynamic conditions that can change during the time of observation. The heterogeneity of our population in terms of endoscopic therapies and retrospective design are limitations of our study.
PG is a well-established source of gastrointestinal bleeding in patients with PH (1,18,33). In a prospective study of 100 adult patients with cirrhotic PH, it was found that the risk of bleeding from PG was accurately reflected by the PG scoring system proposed at Baveno (1). No bleeding was observed in patients who had scores ≤3. In a retrospective study of 22 children with PH, PG was graded using criteria established by McCormack et al, and 0 of 7 patients with mild gastropathy and 2 of 7 patients with severe gastropathy bled from their gastric mucosa (11,23). In another pediatric study of 139 children with biliary atresia, the initial sign of PG was detected at a median age of about 1 year and was shown to be associated with a 5-year actuarial risk of bleeding of 69% compared to a risk of 20% if no PG was present (34). In the present study, all of the patients with PG had scores ≤3 and none bled from PG, similar to previous data. However, GAVE due to PH, which is a component of the Baveno scoring system, is a rare condition in childhood. This makes it less convenient for use in pediatric scoring. We believe that it may be better to report GAVE as a separate positive finding when present in childhood, instead of one of the established parameters of the scoring system.
Histologically, portal hypertensive mucosal lesions correspond to dilated vessels in the mucosa and submucosa in the absence of erosions or inflammation (23,35). In addition, submucosal veins appeared ectatic and irregular with areas of intimal thickening in surgical and autopsy specimens (23). Some studies showed capillary dilation not only in patients with PG but also in controls (36,37) and concluded that there had not been any correlation between endoscopic and histologic findings of PG. Apart from these, the value of endoscopic biopsies in the diagnosis of vascular dilation from the perspective of availability of adequate tissue or sampling error was questioned (38). Large forceps specimens yielded no additional information over standard forceps biopsies when compared to snare biopsy technique (39). Despite these discussions, different studies using different methods, such as silicon injection technique and morphometric analyses with or without endothelial cell markers, supported the relation between capillary dilation and PG (40–42). We found that the only histologic finding showing significant association with the endoscopic diagnosis of PG was capillary dilation.
Edema and capillary dilation were found in the intestinal biopsies of patients with PH (8,10,32); however, statistically significant association between macroscopical PD and histologic findings in portal hypertensive patients was not shown (10). Moreover, similar rates of vascular dilation in patients with PH and control patients with nonulcer dyspepsia were observed (43). Histologic examination of duodenal polyp described in children with PH revealed lobular capillary proliferation in a hemangiomatous pattern in the lamina propria of the duodenal mucosa (44). Similarly, it was concluded that capillary angiogenesis was an important vascular mechanism for adaptation to PH (10). None of the histologic findings correlated with endoscopic diagnosis of PD in the present study; however, we identified a duodenal polyp suggestive of portal hypertensive duodenal mucosal change in 1 of our patients. This lesion had not been noticed in the previous endoscopy session before variceal eradication. Although we did not biopsy the polyp, its development after endoscopic treatment suggested that it was related to PH.
In conclusion, PG and PD are seen in children with extrahepatic and intrahepatic PH at similar rates reported in pediatric and adult studies. Baveno PG scores increased in parallel with Child-Pugh class in children with cirrhosis. Capillary dilation was the only histologic finding showing a significant association with the endoscopic diagnosis of PG in this study. Duodenal polyp seems to be a newly defined mucosal lesion arising in children with PH.
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