Management of variceal bleeding

Variceal hemorrhage complicates cirrhosis in as many as 50% of patients and results in considerable morbidity and mortality. This review covers all areas of importance in the prevention and treatment of this area, highlighting recent developments. Primary prophylaxis prevents first bleed, and pharmacotherapy with beta-blockade is the most widely accepted option. In an acute variceal hemorrhage, initial resuscitation and multiple organ support are paramount and are recommended along with antibiotic prophylaxis and specific medical therapies that may be given empirically before emergency endoscopy to reduce bleeding. Endoscopic techniques usually arrest bleeding, but when they fail, salvage therapy in the form of balloon tamponade, then transjugular intrahepatic portosystemic shunts or surgery, may be appropriate. Secondary prophylaxis to prevent rebleeding is often instituted in the ICU and is vital to prevent recurrence of this life-threatening complication.