Variceal bleeding and portal hypertension

Within the short span of half a century, the treatment of variceal bleeding has become highly differentiated, with multiple treatment options. Pharmacological therapy with beta-blockers is well established for preventing the first variceal bleeding. The utility of adding a vasodilator to beta-blockers needs to be studied further. Octreotide is widely used as an adjuvant to standard endoscopic treatment to prevent variceal rebleeding, and the utility of this approach has been validated in several randomized controlled trials. Band ligation is well established, and its popularity has increased with the introduction of multiple ligation devices. The technical simplicity and safety of band ligation has sparked interest in using this technique for primary prophylaxis of variceal bleeding. However, randomized trials have not shown any advantage for band ligation over beta-blocker therapy, and the high variceal recurrence rate after band ligation may eliminate any theoretical advantage. A synchronous combination of band ligation and sclerotherapy has not been shown to improve the results of band ligation alone, but a metachronous approach using sclerotherapy to treat recurrent varices after band ligation has shown beneficial results. Histoacryl remains the best treatment option for gastric varices, but band ligation and loop ligation have shown promising results, and should be considered when Histoacryl is not available. Balloon-occluded retrograde transvenous obliteration is a new radiological modality for gastric varices, and one that sounds promising. TIPS is well established as an alternative to elective endoscopic treatment. Compared with endoscopic treatment, TIPS has been shown to improve the survival rate in one randomized trial. However, the cost and complications of TIPS have restricted its use. The use of endoscopic ultrasound for Doppler studies of blood flow in portal hypertension is currently investigational, but it may gain a role in selecting the optimal treatment approach for the individual patient.