APSPGHAN Statement on Endoscopic Variceal Bleeding Hemostasis.

Purpose: Endoscopic variceal hemostasis is a critical, life-saving intervention frequently performed by pediatric gastroenterologists. To ensure safe and effective practices, the Asian Pacific Society for Pediatric Gastroenterology, Hepatology and Nutrition Endoscopy Scientific Subcommittee developed a consensus-based position statement. Methods: A comprehensive literature review was conducted with an emphasis on pediatric evidence. Nineteen draft statements were formulated and refined through electronic votes and virtual meetings. Statements with <80% agreement were revised until consensus was reached. Levels of evidence certainty were evaluated to support the final recommendations. Results: Nineteen position statements, covering screening, acute management, and surgical options, were endorsed. Although noninvasive tools such as elastography and platelet-based indices may assist in risk stratification, endoscopy remains the diagnostic and therapeutic gold standard. Endoscopic variceal ligation was identified as the preferred modality for both prophylaxis and treatment in children ≥10 kg, outperforming sclerotherapy and non-selective beta-blockers. Standard acute management incorporates octreotide and restrictive transfusion strategies, with endoscopy performed within 24 hours. In refractory cases, the Meso-Rex stunt or transjugular intrahepatic portosystemic shunt may be considered depending on anatomy and available expertise. Conclusion: These findings provide an evidence-based framework for the management of pediatric variceal bleeding. Individualized care is emphasized while highlighting the pressing need for high-quality pediatric studies to strengthen future recommendations.