Echocardiography, Bile Acids and Spleen Stiffness to Rule Out High‐Risk Varices in Children With Biliary Atresia

BACKGROUND AND AIMS: Detecting gastroesophageal varices with a high risk of bleeding (HRV) in children with biliary atresia requires endoscopies from an early age to apply primary prophylaxis of bleeding. However, repeated endoscopies are invasive and costly. This study was performed to define tools to rule out HRV, with the objective of reducing the number of endoscopies. METHODS: Children with biliary atresia and portal hypertension were prospectively enrolled. Laboratory tests, elastography, echocardiography, and endoscopy were performed. Variables were subjected to principal component analysis, followed by multivariate logistic regression analyses for HRV prediction. The effectiveness of composite models and criteria based on liver and spleen stiffness measurements was evaluated using the missed HRV ratio and the spared endoscopy rate. RESULTS: Among the 100 children enrolled, a higher indexed right atrium area, higher left ventricle end-diastolic diameter, younger age, higher serum bile acid concentration, and higher spleen stiffness were independently associated with HRV. In children under 3 years old, a model combining indexed right atrium area from echocardiography and serum bile acid concentration achieved a 37% spared endoscopy rate with no missed HRV. For children over 3 years old, spleen stiffness of ≤ 30 kPa was associated with a 41% spared endoscopy rate and no missed HRV. CONCLUSION: Combining an echocardiography-based model for children under 3 years old with spleen stiffness criteria for older children may reduce the need for screening endoscopies by 40% in children with biliary atresia and portal hypertension.