Treatment of acute gastroesophageal variceal hemorrhage

About 30% to 35% of patients with portal hypertension bleed from gastroesophageal varices and mortality remains high reflecting the challenges of effectively dealing with the bleeding event itself and the problems of underlying liver disease. Careful resuscitation and control of risk of complications is the most essential element of medical therapy (Fig. 2). Use of newer, more effective drug combinations with vasopressin or somatostatin permit control of hemorrhage in the majority of patients with fewer drug-induced complications. Endoscopic sclerotherapy and, more recently, banding therapy provide immediate control of hemorrhage and eradication of varices and rebleeding in up to 90% of patients. Persistent, recurrent bleeding in the small number of remaining patients can be effectively managed by "portacaval shunt rescue" or orthotopic liver transplantation in selected cases with acceptable surgical morbidity and mortality. The contribution and role of the TIPS procedure is unknown but very promising; at least as a bridge procedure in patients awaiting transplantation. Until appropriate prospective, comparative trials are performed, the role of TIPS as a long-term alternative to portacaval shunt surgery or other endoscopic or surgical options remains unknown.