Management of Variceal Hemorrhage

Variceal hemorrhage is a frequent and lethal complication of portal hypertension. Bleeding occurs in 30%-40% of patients with cirrhosis and varices. The first episode of variceal bleeding is associated with a high mortality as well as a high incidence of re-bleeding. Thus, management of variceal hemorrhage should be categorized into 3 phases: primary prophylaxis (prevention of the first episode of bleeding), emergency treatment (management of acute bleeding), and secondary prophylaxis (prevention of re-bleeding). Modalities involved include pharmacological, endoscopic, surgical, interventional radiological therapy and balloon tamponade. This review summarizes the current choices of management during each phase, and concentrates on the following questions, what can we do to prevent the formation and development of varices; how can we predicate the risk of bleeding; what should we do in case of bleeding; what is the first-line therapy; what should we do when current therapy fails; when should we give up and what is the optimal strategy for secondary prophylaxis.