B) Injection sclerotherapy for long-term treatment :

Injection sclerotherapy was suggested for the treatment of oesophageal varices in children because of failures and complications of primary surgery. Portosystemic shunt thrombosis and rebleeding, the hazards of splenectomy in children and long term risks of encephalopathy all encouraged an alternative therapy. Controlled trials in adult patients confirmed that early endoscopic sclerotherapy after the onset of bleeding significantly reduced the risk of rebleeding and may prolong survival in the cirrhotic. Injections are performed through a flexible upper GI endoscope under general anaesthesia with an endotracheal tube in place. Intravenous sedation has been used occasionally in older children. A variety of sclerosants are available including ethanolamine oleate, sodium tetradecyl sulphate, sodium morrhuate, phenol in almond oil and polidocanol. The injections are given either intra or para-variceal and are mostly given into the cardia and lower 3 cm of the oesophagus. A maximum of 3 ml is injected into each varix to a maximum of 5 to 20 ml per session depending on the age and the size of the patient. A naso-gastric tube is inserted in small infants to control the degree of gastric distension. The initial 3 injections are given at weekly intervals and subsequent treatments on a monthly basis until the varices are obliterated.

Mild symptoms of retrosternal discomfort and a transient fever are common after endoscopic sclerotherapy. The variceal haemorrhage may recur, particularly between the first 2 or 3 treatments and oesophageal ulceration may be followed by stricture formation and dysphagia. Rare serious complications have included broncho-oesophageal fistula, chylothorax and pericarditis. One case of paraplegia has been reported from injection of segmental spinal vessels.

An analysis of seven reports published since 1984 of the results of sclerotherapy in 248 children shows a mortality rate of 3 percent and a rebleed rate of 12 percent. The rebleed rate in a series of 7 reports of surgery for portal hypertension (1980 - 86) was 14 percent.