C) Variceal banding :

This technique, which involves application of an elastic band to a variceal column, is done through flexible upper gastro-intestinal endoscopes. The strangulated varix, subsequently, thromboses and sloughs. Usually up to three bands are applied at each session. Multi-band devices allow the application of several bands without the need for reloading. Treatment is performed initially at 1 to 2 weekly intervals, extending to monthly intervals once the larger varices are treated. The incidence of oesophageal stricture and systemic side-effects is lower with this treatment modality. At present, equipment limitations make this technique difficult to use in small children less than 2 years of age.

D) Transjugular intrahepatic port-systemic shunt (TIPS) :

The indications of TIPS in children include uncontrolled variceal bleeding especially the ones who are awaiting liver transplantation. Some patients of Budd-Chiari syndrome or intractable ascitis may also benefit by this procedure. Portal vein thrombosis, bacterial sepsis and coagulopathy are contraindications to TIPS.

This intervention involves insertion of an expandable metallic stent from the hepatic to the portal vein through the percutaneous transjugular route under radiological guidance. Under fluoroscopic control, a guidewire is passed into a hepatic vein. A needle is then advanced over a guidewire into the hepatic vein and thence to the portal vein. A balloon catheter is subsequently used to dilate the intrahepatic tract and the stent is deployed.