Surgical therapy of acute esophageal variceal hemorrhage

Options for the management of patients with acute variceal hemorrhage must be compared for their ability to stop bleeding and prevent rebleeding, for their safety, and for their impact on hepatic reserve. Pharmacologic treatment may stop bleeding in up to 50% of patients, but cannot prevent rebleeding. Balloon tamponade controls bleeding in 90% of patients but is only transiently effective and may cause complications. Immediate sclerotherapy may stop acute bleeding and may provide chronic control with repeated treatments. However, patients who fail to respond to such measures must be submitted for surgical intervention. Emergency portosystemic shunt or esophageal transection represent the current procedures of choice for these patients. Surgery may also prove more cost effective than repeated sclerotherapy as primary therapy in a select group of patients with a high risk of rebleeding. Ultimately, however, primary pharmacologic therapy or hepatic transplantation to correct the pathophysiology underlying the esophageal variceal hemorrhage must be developed and refined if the natural history of this disease is to be substantially altered.