[Endoscopic and Interventional Therapy of Acute Variceal Bleeding: Endoscopy, EUS, TIPS and BRTO]

Acute variceal bleeding is a time-critical gastroenterological emergency requiring a structured interdisciplinary approach. When variceal bleeding is suspected, vasoactive therapy and intravenous antibiotics should be started before endoscopy; in hemodynamically stable patients, esophagogastroduodenoscopy should be performed within 12 hours. Endoscopic hemostasis depends on the bleeding site: endoscopic variceal ligation is preferred for esophageal varices, whereas (n-butyl-2-)cyanoacrylate injection is standard for fundal or gastric varices. In specialized centers, endohepatology broadens treatment options: EUS-guided coil deployment combined with cyanoacrylate allows targeted obliteration of gastric varices (GOV2, IGV), particularly when TIPS is not feasible. High-risk patients (Child-Pugh B >7 with active bleeding at index endoscopy or Child-Pugh C <14) benefit from pre-emptive TIPS within 72 hours if no contraindications exist. In primary treatment failure, eligibility for salvage TIPS and transfer to an expert center should be assessed early; a fully covered self-expanding esophageal metal stent can bridge refractory esophageal variceal bleeding. If TIPS or EUS are not an option, BRTO is increasingly relevant-when anatomy is suitable, especially with a gastrorenal shunt-for GOV2, isolated gastric and ectopic varices.