Résumé
L’hémorragie du tractus digestif supérieur constitue une menace vitale pour l’enfant cirrhotique. Cet événement peut s’accompagner de choc hypovolémique, d’insuffisance hépatique, de sepsis et conduire au décès. La sclérose des varices en urgence peut être réalisée par voie endoscopique. Le contrôle du saignement est obtenu par cette technique dans plus de 90 % des patients traités. La sclérothérapie itérative est ensuite nécessaire pour obtenir l’occlusion variqueuse et prévenir la récidive hémorragique.
Lorsque la sclérothérapie ne contrôle pas les saignements, la mise en place transjugulaire d’une prothèse porto-systémique hépatique (TIPSS) peut réduire l’hypertension portale même chez le petit enfant. Enfin, les enfants souffrant d’une affection hépatique très décompensée sont programmés en vue d’une transplantation hépatique, ce qui procure un taux de survie à long terme de l’ordre de 80 %. L’association de ces divers moyens thérapeutiques diminue à présent de façon considérable la mortalité associée au saignement aigu sur varices chez cette catégorie de patients.
Summary
Upper gastrointestinal bleeding is a life threatening event in the cirrhotic child. Hypovolemic shock, liver insuficiency and sepsis may complicate the course and cause death. Emergency variceal sclerosis can be performed endoscopically. Bleeding control is achieved with this technique in up to ninety percent of the patients. Iterative sclerotherapy is thereafter needed to achieve variceal occlusion and prevent secondary bleeding.
When sclerotherapy fails to control bleeding, transjugular intra-hepatic portosystemic stent shunt (TIPSS) can be placed even in small children to relieve portal hypertension. Finally, children with advanced liver disease are proposed for liver transplantation, with a eighty percent long term survival. The combination of these therapies has now decreased considerably the mortality associated to acute variceal bleeding in these patients.
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Bauraind, O., Van Obbergh, L., Veyckemans, F. et al. Conduite à adopter chez l’enfant en présence de saignement du tractus digestif supérieur par hémorragie sur varices œso-gastriques. Acta Endosc 24, 403–410 (1994). https://doi.org/10.1007/BF02970065
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DOI: https://doi.org/10.1007/BF02970065
Mots-clés
- dérivation porto-cave
- endoscopie
- enfant
- hémorragie gastrointestinale
- sclérothérapie
- TIPSS
- transplantation hépatique orthotopique
- varices