Emerging strategies in the management of upper gastrointestinal bleeding

Variceal hemorrhage is the most serious complication of portal hypertension and is associated with a high mortality rate. The first stage of treatment is to stabilize the patient, followed by emergency diagnostic endoscopy to identify the source of bleeding. If active variceal bleeding is found, endoscopic intervention by sclerotherapy or band ligation is performed to induce hemostasis. Sclerotherapy achieves hemostasis through the induction of thrombosis and/or by external compression of the vessel; band ligation by physical constriction of the varix. Both techniques are difficult to perform during active bleeding. This has prompted the search for improved treatment protocols. Vasoactive drugs which lower portal pressure have been used for years as an alternative to endoscopic treatment. Recently, the combined use of such drugs and either sclerotherapy or banding has been proposed. Data from several trials have suggested that pharmacotherapy in combination with endoscopic intervention is more effective than endoscopic treatment alone. Furthermore, pharmacotherapy continued for 5 days following endoscopy significantly reduces the incidence of early rebleeding. Thus, therapeutic regimens combining vasoactive drugs and endoscopic therapy are likely to replace, in the near future, the usual approaches based on endoscopic or pharmacological treatment alone.