Management of portal hypertension

Although bleeding from esophagogastric varices remains a major cause of morbidity and mortality in patients with cirrhosis, recent advances in treatment show promise. Sclerotherapy is the accepted therapy for control of acute variceal bleeding. Endoscopic ligation of varices may be a reasonable alternative, with potentially fewer side effects. Pharmacological agents continue to have a role for initial treatment and as an adjunct to sclerotherapy. For patients who do not respond to medical management, either esophageal staple transection or the transjugular intrahepatic portasystemic shunt (TIPS) procedure is a reasonable rescue procedure and may be preferable to emergency portasystemic shunts. Both long-term sclerotherapy and nonselective beta blockers are effective in reducing the incidence of recurrent bleeding, but they are only marginally effective in improving survival. Endoscopic variceal ligation is currently under evaluation as a potential alternative to sclerotherapy. For patients unresponsive to medical therapy, the decision regarding a surgical shunt or liver transplantation will depend on each patient's clinical status and acceptability as a transplant candidate. The TIPS procedure may be useful in preventing rebleeding for patients awaiting transplantation. Nonselective beta blockers are effective in reducing the risk of first variceal hemorrhage, which is the ultimate goal of therapy, but they have shown only minimal benefit for survival. Shunt surgery and sclerotherapy are not indicated for prophylactic treatment. Future research will involve better identification of patients at high risk for variceal hemorrhage and evaluation of combinations of pharmacological and endoscopic therapies to prevent bleeding and to improve survival.