Somatostatin for Esophageal Variceal Bleeding

liver411

[B]in the Pediatric Patient?[/B]

Gastroenterology Ask The Expert

Posted 07/15/2003


from Medscape Gastroenterology


Question
What is the role of somatostatin in the management of esophageal variceal
bleeding in children, including indications, dosage, and efficacy?

Pham Thi Ngoc Tuyet, MD

Response
from M. Brian Fennerty, MD, 07/15/2003

Therapy for any disease process ideally is judged by the results of a
properly designed clinical trial that includes randomization with concealed
allocation, double-blinding, a complete accounting of all patients entered
into the study, and an analysis by intention-to-treat methodology. Although
the use of somatostatin and its analogues (octreotide) has been evaluated
extensively in high-quality studies (as outlined above) and shown to be
effective in adults, this level of investigation has not occurred in
children with portal hypertension-related bleeding. Instead, we only have
observational evidence regarding the safety and effectiveness of these
agents in the setting of pediatric disease.

Siafakas and colleagues[1] reported on their use of octreotide in children
with severe gastrointestinal bleeding from 1993 to 1995. Patients either
received a 50-microgram (mcg) bolus followed by a 50-mcg infusion/hour (the
adult dose of octreotide) or a 1-2-mcg/kg bolus followed by an infusion of 1
mcg/hour. In most cases, these doses were then tapered by 50% every 12 hours
if no active bleeding was noted and stopped when a dose one fourth of the
original was achieved. Bleeding stopped in 6 of 7 patients (all 6 of whom
had nonarterial hemorrhage) and recurred in 2, again controlled with
reinstitution of the octreotide infusion. Only 1 case of hyperglycemia was
noted.

Zellos and Schwarz[2] reported their experience with daily subcutaneous
octreotide (4-8 mcg/kg/day) in 3 children with chronic gastrointestinal
bleeding. Bleeding was controlled with this therapy regimen, and other than
a decrease in serum thyroid-stimulating hormone in 1 patient, no other
toxicity was noted as attributable to the octreotide therapy.

Gonzalez and colleagues[3] reported on the use of chronic subcutaneous
octreotide in a pediatric patient with blue rubber-bleb nevus syndrome and
chronic hemorrhage. Octreotide given at a dose of 5.7 mcg/kg/subcutaneously
twice daily decreased the patient's need for blood transfusion.

Lam and colleagues[4] have also used octreotide as a therapeutic agent for
diverse disease settings -- including gastrointestinal bleeding,
pancreatitis, chylous leaks, and hypoglycemia -- in 10 infants and children.
Evidence for efficacy, with little associated toxicity, was noted in this
observational experience.

In summary, the physiologic rationale for using octreotide or somatostatin
analogues in portal hypertensive bleeding is sound and of proven value in
adults. Its use in children appears to have some value, although there are
no high-quality studies documenting its application in this setting. Its use
appears to be safe in the pediatric population, but data regarding safety
are also very limited. The dose used in children has varied widely and the
optimal dosing regimen has not yet been determined.

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References
Siafakas C, Fox VL, Nurko S. Use of octreotide for the treatment of severe
gastrointestinal bleeding in children. J Pediatr Gastroenterol Nutr.
1998;26:356-359. Abstract
Zellos A, Schwarz KB. Efficacy of octreotide in children with chronic
gastrointestinal bleeding. J Pediatr Gastroenterol Nutr. 2000;30:442-446.
Abstract
Gonzalez D, Elizondo BJ, Haslag S, et al. Chronic subcutaneous octreotide
decreases gastrointestinal blood loss in blue rubber-bleb nevus syndrome. J
Pediatr Gastroenterol Nutr. 2001;33:183-188. Abstract
Lam JC, Aters S, Tobias JD. Initial experience with octreotide in the
pediatric population. Am J Ther. 2001;8:409-415. Abstract
About the Panel Members
M. Brian Fennerty, MD, Professor of Medicine, Section Chief of
Gastroenterology, Oregon Health Sciences University, Portland, Oregon

Medscape Gastroenterology 5(2), 2003. © 2003 Medscape