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Endoscopic retrograde cholangiopancreatography (ERCP) is increasingly utilized for management of biliary disorders in children and adolescents. Practice patterns surrounding cholangioscopy in pediatric patients, however, are largely uncharacterized.We retrospectively analyzed all ERCPs in which cholangioscopy was performed on patients 18 and under at our tertiary care children's hospital from 2015 to 2020 using our institution's paper and electronic medical record system. Patient demographics, procedure indications, interventions, and associated adverse events were analyzed.Over the study period, 307 ERCPs were performed on 282 patients at our children's hospital. Cholangioscopy was performed in 36 procedures (11.7%) using the SpyGlass cholangioscope (Boston Scientific). Antibiotics to cover biliary organisms were administered to all patients precholangioscopy. Mean patient age was 13.6 years (range 7-18 years). The 2 most common indications for cholangioscopy included electrohydraulic lithotripsy for biliary stone disease and evaluation of biliary stricture (with incidental finding of biliary web in 2 patients and retained suture material in 2 patients). Adverse events were less prevalent in patients who underwent cholangioscopy relative to those who underwent ERCP. 0/36 (0%) developed post-ERCP pancreatitis, one patient had self-limited melena (possible self-limited postsphincterotomy bleeding). Patient care was enhanced by cholangioscopy in 30/36 (83.3%) of these patients.These data attest to the safety and clinical utility of cholangioscopy in children and adolescents. Cholangioscopy was performed in just over 11% of pediatric patients who underwent ERCP at our academic medical center-rates similar to those reported in adult patients. The radiation-sparing nature of cholangioscopy, coupled with these data supporting its safety, make it particularly appealing for use in children. Further multi-institution evaluation of the utility, safety, and range of indications for cholangioscopy in other practice settings would be of great interest and help guide endoscopic care.

(1) Background: Abnormal liver function tests are commonly encountered in clinical practice, often leading to additional workup to determine the underlying etiology of these abnormal laboratory studies. As part of this evaluation, if less invasive imaging studies are performed and are without evidence of biliary obstruction, liver biopsy may be performed, and the finding of large duct obstruction on liver biopsy is commonly encountered. The utility of endoscopic retrograde cholangiopancreatography (ERCP) for evaluation and management of possible biliary obstruction in patients with large duct obstruction on liver biopsy has not been studied to date. (2) Methods: To assess the utility of ERCP in patients with large bile duct obstruction on liver biopsy, we retrospectively evaluated patients with large duct obstruction on liver biopsy from 2010–2019 at our tertiary care and transplant center. Demographic and clinical characteristics were evaluated for all patients, with sub-group analysis for patients who underwent ERCP and those who had intervenable findings at the time of ERCP. Descriptive statistics with proportions, means, and standard deviations were performed for demographics and clinical variables using absolute standardized difference. (3) Results: During the study period, 189 liver biopsies with evidence of large duct obstruction were performed. After exclusion criteria were applied, 166 unique patients were eligible for the study. Ninety-one patients with evidence of large duct obstruction on liver biopsy underwent ERCP and 75 did not. Of the 91 patients who underwent ERCP, 76 patients (84%) had an intervenable finding at ERCP. Patients who underwent ERCP were overall more likely to have had a liver transplant (65% ASD 0.63), have previously undergone cholecystectomy (80%, ASD 0.56), and be immunocompromised (80%, ASD 0.56). (4) Conclusions: ERCP is high yield when large duct obstruction is apparent on liver biopsy, with the majority of patients (84%) who undergo ERCP in this clinical context having a biliary finding necessitating therapeutic endoscopic intervention.

Endoscopic procedures are increasingly performed for children and adolescents and these interventions represent a central element of both pediatric gastroenterology (GI) care and revenues. It remains unclear, however, which scheduling paradigm maximizes efficiency of resource utilization and delivery of care in this arena. In this study, we evaluate the impact of shifting from shared endoscopy blocks to individual, provider-specific endoscopy blocks for scheduling endoscopic procedures in our tertiary care academic center.The implemented endoscopy block system involves a single endoscopist performing procedures in an allocated room for the entire half-day period of time, with most providers having 1-3.5 day blocks per month. We analyzed block fragmentation (multiple providers in a single block), block utilization, and procedure volume, comparing the 8-month period prior to implementation of the block system (pre-implementation period) with the 8-month period following implementation of the block system (post-implementation period). Provider satisfaction and perceptions were assessed by survey pre- and post-implementation. Standard descriptive statistics were utilized for analysis.In the pre- and post-implementation periods, 22 half-day blocks were allocated to pediatric GI. In the pre-implementation period, mean utilization of these blocks was 65.9% (range: 47%-77%). In the post-implementation period, mean % utilization was 79.8% (range: 64%-89%). Overall endoscopy procedure volume increased from 279 in the pre-implementation period to 419 in the post-implementation period. Provider perception of endoscopy efficiency was enhanced by the block system, with 68.4% of pediatric GI respondents rating endoscopy as "efficient" post-implementation (vs 19% pre-implementation) and 63.2% indicating that the block system directly enhanced efficiency. A total of 63.2% reported increased personal procedure volume and 84.2% reported perceived increase in overall procedure volume with block system implementation.Strategic approaches for scheduling endoscopic procedures carry the potential to enhance efficiency and experience for both providers and patients. Implementation of the endoscopy block system was associated with increased procedure volumes and block utilization as well as a more positive experience for the majority of providers. Schedule adjustments with analysis of associated efficiency and satisfaction metrics can optimize pediatric endoscopy practice.

Endoscopic retrograde cholangiopancreatography (ERCP) in adults has been extensively studied through multicenter prospective studies. Similar pediatric studies are lacking. The Pediatric ERCP Database Initiative (PEDI) is a multicenter collaborative aiming to evaluate the indications and technical outcomes in pediatric ERCPs.In this prospective cohort study, data were recorded for pediatric ERCPs performed across 15 centers. A pre-procedure, procedure, 2-week post-procedure follow-up, and adverse event form were completed for each ERCP performed. Univariate and stepwise linear regression was performed to identify factors associated with technically successful procedures and adverse events.A total of 1124 ERCPs were performed on 857 patients from May 1, 2014 to May 1, 2018. The median age was 13.5 years [interquartile range (IQR) 9.0-15.7]. Procedures were technically successful in the majority of cases (90.5%) with success more commonly encountered for procedures with biliary indications [odds ratio (OR) 4.2] and less commonly encountered for native papilla anatomy (OR 0.4) and in children3 years (OR 0.3). Cannulation was more often successful with biliary cannulation (95.9%) compared to pancreatic cannulation via the major papilla (89.6%, P0.0001) or minor papilla (71.2%, P0.0005). The most commonly identified adverse events included post-ERCP pancreatitis (5%), pain not related to post-ERCP pancreatitis (1.8%), and bleeding (1.2%). Risk factors for the development of each were identified.This large prospective study demonstrates that ERCP is reliable and safe in the pediatric population. It highlights the utility of PEDI in evaluating the technical outcomes of pediatric ERCPs and demonstrates the potential of PEDI for future studies in pediatric ERCPs.

Background Endoscopic retrograde cholangiopancreatography (ERCP) is a fluoroscopy and endoscopy-based procedure important for diagnosis and management of pediatric pancreaticobiliary disorders. Patient, procedure, endoscopist and facility characteristics have been shown to influence ERCP complexity and procedure outcomes as well as fluoroscopy utilization in adults, however the extent to which this is true in pediatric patients remains under-studied and there are minimal data regarding fluoroscopy utilization in pediatric ERCP. Methods We retrospectively analyzed ERCPs performed on patients 100 and low volume endoscopists (LVE) as Results 385 ERCPs performed on 321 patients were included in this analysis. The mean patient age was 13.4 years (+/- 4.2 years), 77% were index ERCPs (native ampullas) and 81% were performed with therapeutic intent (87% for biliary indication and 13% for pancreatic indication). Fluoroscopy times varied dramatically between procedures and providers. Median fluoroscopy time was 4.85 (+/- 2.68) minutes. Endoscopist annual ERCP volume was the strongest predictor of fluoroscopy time (p 16 years at the time of ERCP (p Conclusions Radiation exposure is higher than desirable for pediatric ERCP and varies with endoscopist as well as patient and procedure-specific factors. HVE perform ERCP with lower fluoroscopy time relative to LVE even though HVE procedure complexity was higher. The Stanford Fluoroscopy Score predicted fluoroscopy time for pediatric ERCP, but the ASGE ERCP complexity scale did not. Adaptation and refinement of pediatric-specific ERCP complexity scales including factors such as patient size and age and indications/interventions more consistent with those encountered in pediatrics could be beneficial.

Background Gastric variceal (GV) bleeding is among the most morbid sequelae of portal hypertension, with mortality ranging from 30% to 50%. Pediatric data focused on endoscopic approaches to management are needed. The present study represents the first pediatric case series of endoscopic ultrasound (EUS)-guided coil placement within feeding vessels as monotherapy for management of GV bleeding. Methods Using our prospectively maintained endoscopy database, we identified patients 18 years and younger who underwent EUS-guided coil placement for management of GV bleeding from 2008 to 2018. Demographics, indication, procedural interventions/findings, and available clinical outcomes data were analyzed. Results Twelve patients (median age 15, range 11-18 years) underwent EUS-guided coil placement for GV bleeding. All had portal hypertension, with EV in 58.3% and prior GV bleeding with attempted endoscopic management in 75%. Coil placement was accomplished using a linear echoendoscope and a 19-gauge needle. A mean of 2.75 (± 0.43) coils were placed in each patient (4, 6, 8, and 10 mm Nester Embolization Coils, Cook Medical, Bloomington, Indiana, USA). Immediate hemostasis was achieved in all patients, and 25% of patients developed recurrent gastric varices at a median of 5.5 months following the initial EUS-guided coil placement (range 4-6 months) over the median 12 month follow-up period. Conclusions The present study establishes the feasibility and efficacy of EUS-guided coil placement as monotherapy for GV bleeding in children and adolescents. The technique was technically successful, with primary hemostasis achieved in all patients. EUS-guided embolization with coils may represent an alternative to current approaches for management of highly morbid GV bleeding.

Endoscopic ultrasound (EUS) is a commonly used radiation-sparing procedure in adult patients for diagnostic sampling of gastrointestinal lesions and fluid collections, gastric variceal hemostasis, biliary/pancreatic duct drainage, and endo-surgical interventions. Integration of EUS in pediatrics is still in its infancy with limited data regarding its use. The present study analyzes utilization, diagnostic and therapeutic roles of pediatric EUS and evolution in these parameters over time.Records of patients 18 years or younger from 2009 to 2020 at our tertiary pediatric care center were retrospectively identified. Patient demographics, symptoms, laboratory studies, EUS indications and interventions, and clinical outcomes of the procedures were analyzed. Statistical analysis was performed using Student t-test, Pearson's chisquare and Fisher exact tests.306 EUS procedures were performed during the study period, for 279 pediatric patients. These included 287 (93.8%) upper EUS and 19 (6.2%) lower EUS. Two hundred and twenty-nine procedures were diagnostic (74.8%) and 77 were therapeutic (25.2%). EUS indications included evaluation and therapy of the pancreaticobiliary region (231, 75.5%), subepithelial or regional lesion (54, 17.8%), celiac plexus block (19, 6.2%) and hemostasis (14, 4.5%). Diagnostic sampling was performed in 52 of these EUS procedures, with a 96.2% diagnostic yield. 98.7% of therapeutic procedures were technically successful and there were no associated adverse events.The diagnostic and therapeutic role for EUS in adults has expanded dramatically, however the role of EUS in pediatrics is not well-defined. In this, the largest pediatric EUS study to date, our data support the safety and utility of diagnostic and therapeutic EUS in pediatrics.

Systemic steroid exposure, while useful for the treatment of acute flares in inflammatory bowel disease (IBD), is associated with an array of side effects that are particularly significant in children. Technical advancements have enabled locoregional intraarterial steroid delivery directly into specific segments of the gastrointestinal tract, thereby maximizing tissue concentration while limiting systemic exposure. We investigated the feasibility of intraarterial steroid administration into the bowel in a cohort of nine pediatric patients who had IBD. This treatment approach provided symptom relief in all patients, with sustained relief (>2 weeks) in seven out of nine; no serious adverse effects occurred in any patient. In addition, we identified patterns of vascular morphologic changes indicative of a vasculopathy within the mesenteric circulation of inflamed segments of the bowel in pediatric patients with Crohn’s disease, which correlated with disease activity. An analysis of publicly available transcriptomic studies identified vasculitis-associated molecular pathways activated in the endothelial cells of patients with active Crohn’s disease, suggesting a possible shared transcriptional program between vasculitis and IBD. Intraarterial corticosteroid treatment is safe and has the potential to be widely accepted as a locoregional approach for therapy delivery directly into the bowel; however, this approach still warrants further consideration as a short-term “bridge” between therapy transitions for symptomatic IBD patients with refractory disease, as part of a broader steroid-minimizing treatment strategy.

Background and aims Ionizing radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP) is an important quality issue especially in children. We aim to identify factors associated with extended fluoroscopy time (FT) in children undergoing ERCP. Methods ERCP on children ≤18 years from 15 centers were entered prospectively into a REDCap database from 5/2014 until 5/2018. Data were retrospectively evaluated for outcome and quality measures. A univariate and step-wise linear regression analysis was performed to identify factors associated with increased FT. Results 1073 ERCPs performed in 816 unique patients met inclusion criteria. Median age was 12.2 years (IQR 9.3-15.8). 767 (71%) patients had native papillae. The median FT was 120 seconds (IQR 60-240). Factors associated with increased FT included procedures performed on patients with chronic pancreatitis, ERCPs with ASGE difficulty grade ≥3, ERCPs performed by Pediatric Gastroenterologist (GI) with Adult GI supervision, and ERCPs performed at non-free standing children's hospitals. Hispanic ethnicity was the only factor associated with lower FT. Conclusion Several factors were associated with prolonged FTs in pediatric ERCP that differed from adult studies. This underscores that adult quality indicators cannot always be translated to pediatric patients. This data can better identify children with higher risk for radiation exposure and improve quality outcomes during pediatric ERCP. An infographic is available for this article at:http://links.lww.com/MPG/C570.

Postoperative esophageal leak is a serious adverse event that occurs in up to 20% following esophageal surgery. Increasingly, endoscopy is utilized to manage leaks refractory to surgical washout and drainage including endoscopic vacuum-assisted closure (EVAC) using negative pressure therapy to achieve source control and granulation. In this report, successful use of this endoscopic strategy to seal a persistent leak after esophageal diverticulectomy is described. A two-year-old male born with esophageal atresia and tracheoesophageal fistula underwent primary anastomosis on the first day of life. Two years later, he presented symptomatic from a diverticulum at the anastomosis and underwent diverticulectomy complicated by esophageal leak at the diverticulectomy site. Despite multiple surgical interventions to seal the leak and obtain source control, the esophageal leak persisted. A multidisciplinary team of surgeons, gastroenterologists, and radiologists determined in consensus with the family of the patient to proceed with EVAC beginning with intracavitary placement of a dressing sponge secured on a nasoesophageal tube. After six endoscopic sessions, the esophageal leak was determined to be closed on endoscopic and fluoroscopic imaging. The patient was ultimately discharged home nine days after removal of the endoscopic vacuum. The leak site remained closed on fluoroscopic esophagram studies performed 6 months later. Negative pressure therapy successfully closed a refractory esophageal leak in a child resulting from diverticulectomy. Future investigations should employ larger series to compare the efficacy, tolerance, and duration of therapy needed to close leaks from EVAC versus stenting.

Endoscopic retrograde cholangiopancreatography (ERCP) is a fluoroscopy and endoscopy-based procedure important for diagnosis and management of pediatric pancreaticobiliary disorders. Patient, procedure, endoscopist, and facility characteristics have been shown to influence ERCP complexity and procedure outcomes as well as fluoroscopy utilization in adults; however, the extent to which this is true in pediatric patients remains under-studied and there are minimal data regarding fluoroscopy utilization in pediatric ERCP.We retrospectively analyzed ERCPs performed on patients18 years of age at our tertiary care children's hospital from 2002 to 2017 using our institution's paper and electronic medical record system along with a prospectively maintained radiation exposure database. Procedure complexity was graded using the Stanford Fluoroscopy Complexity Score and the American Society of Gastrointestinal Endoscopy Complexity scale. High-volume endoscopists (HVE) were defined as having a cumulative annual ERCP volume100 and low-volume endoscopists (LVE) as100 (pediatric + adult) ERCPs/year.Three hundred eighty-five ERCPs performed on 321 patients were included in this analysis. The mean patient age was 13.4 years (+/- 4.2 years), 77% were index ERCPs (native ampullas), and 81% were performed with therapeutic intent (87% for biliary indication and 13% for pancreatic indication). Fluoroscopy times (FTs) varied between procedures and providers. Median FT was 4.85 (+/- 2.68) minutes. Endoscopist annual ERCP volume was the strongest predictor of FT (P 0.001). In addition to endoscopist volume, procedure-specific predictors of increased FT included pancreatic indication for the procedure, biliary or pancreatic duct stricture, patient age4 years or16 years at the time of ERCP (P 0.01 for each), and native ampulla. ERCP complexity rating based on the Stanford Fluoroscopy Complexity Score correlated with FT.Radiation exposure is higher than desirable for pediatric ERCP and varies with endoscopist as well as patient and procedure-specific factors. HVE perform ERCP with lower FT relative to LVE even though HVE procedure complexity was higher. The Stanford Fluoroscopy Score predicted FT for pediatric ERCP, but the ASGE ERCP complexity scale did not. Adaptation and refinement of pediatric-specific ERCP complexity scales including factors, such as patient size and age and indications/interventions more consistent with those encountered in pediatrics could be beneficial.

To analyze outcome and utilization trends over time of pediatric endoscopic retrograde cholangiopancreatography (ERCP) in an all-capture US population-level study.Using the National Inpatient Sample (2005-2014) and National Readmission Database (2010-2014), we identified pediatric (age20 years) hospitalizations during which ERCP was performed and assessed ERCP-associated readmissions. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify hospitalization diagnoses, comorbidities, and patient/hospital characteristics. Multivariate logistic regression analyses were performed to determine significant predictors (P .05) of 30-day readmission.A total of 11 060 hospitalized pediatric patients underwent ERCP between 2005 and 2014. Most were female (n = 8859; 81%), aged 14-20 years (n = 9342; 84%), and white (n = 4230; 45%). Most (85%) of ERCPs were therapeutic, and leading indications were biliary (n = 5350; 48%) and pancreatitis (n = 3218; 29%). Thirteen pecent of patients were readmitted post-ERCP. Odds for 30-day readmission were highest for patients with a history of liver transplantation, age 0-4 years, male sex, and obesity (P .001 for each). Patients in both urban teaching and urban hospitals had much lower odds than those in rural hospitals for prolonged length of stay associated with ERCP.These data represent a comprehensive study of nationwide trends in age-specific volumes and outcomes following ERCP in the pediatric population and provide important insights into trends in pediatric pancreaticobiliary disease management, as well as practice setting, patient characteristics, and patient comorbidities associated with pediatric post-ERCP outcomes, including readmission and length of stay.

Introduction Pediatric chronic pancreatitis is increasingly diagnosed. Endoscopic methods [endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography (ERCP)] are useful tools to diagnose and manage chronic pancreatitis. Pediatric knowledge and use of these modalities is limited and warrants dissemination. Methods Literature review of publications relating to use of ERCP and EUS for diagnosis and/or management of chronic pancreatitis with special attention to studies involving 0--18 years old subjects was conducted with summaries generated. Recommendations were developed and voted upon by authors. Results Both EUS and ERCP can be used even in small children to assist in diagnosis of chronic pancreatitis in cases where cross-sectional imaging is not sufficient to diagnose or characterize the disease. Children under 15 kg for EUS and 10 kg for ERCP can be technically challenging. These procedures should be done optimally by appropriately trained endoscopists and adult gastroenterology providers with appropriate experience treating children. EUS and ERCP-related risks both include perforation, bleeding and pancreatitis. EUS is the preferred diagnostic modality over ERCP because of lower complication rates overall. Both modalities can be used for management of chronic pancreatitis -related fluid collections. ERCP has successfully been used to manage pancreatic duct stones. Conclusion EUS and ERCP can be safely used to diagnose chronic pancreatitis in pediatric patients and assist in management of chronic pancreatitis-related complications. Procedure-related risks are similar to those seen in adults, with EUS having a safer risk profile overall. The recent increase in pediatric-trained specialists will improve access of these modalities for children.

Positive parental attitudes towards infant feeding are an important component in child nutritional health. Previous studies have found that participants in the Special Supplemental Women, Infants, and Children (WIC) Program have lower breastfeeding rates and attitudes that do not contribute towards healthy infant feeding in spite of breastfeeding and nutrition education programs targeting WIC participants. The objective of this study was to assess the frequency of exclusive breastfeeding in the early postpartum period and maternal attitudes towards breastfeeding in a population of mothers at two San Francisco hospitals and in relation to WIC participation status.We interviewed women who had recently delivered a healthy newborn using a structured interview.A high percentage (79.8%) of our sample was exclusively breastfeeding at 1-4 days postpartum. We did not find any significant differences in rates of formula or mixed feeding by WIC participant status. Independent risk factors for mixed or formula feeding at 1-3 days postpartum included Asian/Pacific Islander ethnicity (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.17-7.19). Being a college graduate was associated with a decreased risk of formula/mixed feeding (OR 0.28, 95% CI 0.10-0.79). We also found that thinking breastfeeding was physically painful and uncomfortable was independently associated with not breastfeeding (OR 1.41, 95% CI 1.06-1.89).Future studies should be conducted with Asian-Americans and Pacific Islanders to better understand the lower rates of exclusive breastfeeding in this population and should address negative attitudes towards breastfeeding such as the idea that breastfeeding is painful or uncomfortable.

Fulminant hepatic failure (FHF) in children is a rare but often fatal event. Our knowledge of this disorder is limited by the rarity of the disorder at any single center. Initiatives are underway to accumulate the experience of several large centers in a multicenter study of pediatric FHF in children funded by the NIH (the Pediatric Acute Liver Failure Study Group). Most FHF cases in children remain without a cause. The mechanisms whereby hepatocytes undergo cell death are unknown, as is an understanding of the events leading to FHF and its progression. Therapy has focused on supportive care in an attempt to ameliorate complications, and early referral to a liver transplant center remains crucial. Outcomes are dependent upon the etiology and the degree of CNS involvement. Clinical trials of liver assist devices, hepatocyte transplantation and use of N-acetylcysteine for nonacetaminophen-induced FHF may hold promise for the future.

Seventy-three medical records of pediatric patients admitted for acetaminophen overdose were reviewed. Twenty-eight patients (39%) had severe liver toxic effects, and six of them underwent liver transplantation. Multiple miscalculated overdoses given by parents, with delay in therapy, are risk factors and the major cause of overdose in children 10 years of age or younger.

The objective of this study was to evaluate the relationship between maternal nutrition knowledge and maternal socio-demographics including participation in the Special Supplemental Women, Infants and Children's (WIC) Program. A cross-sectional study of new mothers at two San Francisco hospitals was conducted using some of the American Academy of Pediatrics' guidelines in a structured questionnaire to assess maternal nutritional knowledge. Maternal nutritional attitudes towards product nutrient labels were also assessed in a questionnaire format. Logistic regression models were used to evaluate the odds of having high maternal nutrition knowledge and of infrequently reading nutrition labels. In multivariate logistic regression models, higher maternal nutrition knowledge (defined as answering all four nutrition questions correctly) was associated with higher income levels defined as > or =$25 000/year, odds ratio (OR) 10.03 95% confidence interval (CI) (1.51-66.74), and in linear models, higher nutritional knowledge was associated with having more children (P < 0.01), a higher income (P = 0.01) and not being a WIC participant (P < 0.01). Mothers with higher incomes were also more likely to read product nutritional labels OR 4.24, 95% CI (1.24-14.51), compared with mothers with lower incomes as were mothers with higher education levels OR 3.32, 95% CI (1.28-8.63). In San Francisco, lower income mothers are at greatest risk for low maternal nutrition knowledge and not reading product nutritional labels. Higher household income was independently associated with increased maternal nutrition knowledge and likelihood of reading nutritional labels. More comprehensive interventions need to target low-income mothers including current WIC participants to help close the nutritional advantages gap conferred by income and education.

Management of portal hypertension in children has evolved over the past several decades. Portal hypertension can result from intrahepatic or extrahepatic causes. Management should be tailored to the child based on the etiology of the portal hypertension and on the functionality of the liver. The most serious complication of portal hypertension is gastroesophageal variceal bleeding, which has a mortality of up to 30%. Initial treatment of bleeding focuses on stabilizing the patient. Further treatment measures may include endoscopic, medical, or surgical interventions as appropriate for the child, depending on the cause of the portal hypertension. β-Blockers have not been proven to effectively prevent primary or secondary variceal bleeding in children. Sclerotherapy and variceal band ligation can be used to stop active bleeding and can prevent bleeding from occurring. Transjugular intrahepatic portosystemic shunts and surgical shunts may be reserved for those who are not candidates for transplant or have refractory bleeding despite medical or endoscopic treatment.

Background. H pylori infections are implicated as the cause of nearly all primary (no other known cause) gastritis (PG), especially primary chronicactive gastritis (PCAG). Recent data in adults and children suggest that the association of H pylori and primary gastric and duodenal ulcers may be less than previously reported. To determine whether the association of H pylori and PCAG in children is also lower than initially thought, we reviewed the biopsies of all children undergoing upper GI endoscopy (EGD) at UCSF. Methods. Gastric biopsies obtained from children at UCSF from 1/1/98-8/1/99 were reviewed in a blinded fashion by one GI pathologist. At least 3 specimens from the antrum, fundus, and/or cardia were obtained from each child and were stained with hematoxylin and eosin. Histologic evidence of inflammation was evaluated using the modified Sydney criteria. Specimens demonstrating PCAG but no H. pylori were stained with Giemsa. Patients were excluded from the analysis if they had a known cause for PG. Results. Biopsies from 153 patients (56% male) were evaluated. The mean age was 8.7 (±5.5, std dev) years for all patients, 11.6 (±4.9) years for patients with PCAG and 12.7 (±4.1) years for those with H pylori . The Table shows the rates of PG, PCAG, and H. pylori: All children with H pylori had PCAG but nearly half of the children with PCAG (10/22) had no evidence of H pylori. Significantly more older children (10-20 yrs) had PCAG (p H pylori is a common cause of PCAG but nearly half of the cases of PCAG are idiopathic. These data indicate that the association of H pylori and PCAG is lower than suggested by published reports.