[Non-surgical treatment of portal hypertension]

The choice of methods for the treatment of acute variceal hemorrhage critically depends on the locally available expertise. Vasoactive drugs or balloon tamponade may bridge the time to more definitive measures such as sclerotherapy or band ligation. Drugs (nonselective beta-adrenergic blockers and long-acting nitrates) are almost equivalent to endoscopic sclerotherapy for the prevention of recurrent bleeding, while band ligation offers both increased efficacy (reduced rate of rebleeding and death) and decreased complication rates when compared to sclerotherapy. Thus, ligation will predominantly be used for the prevention of recurrent bleeding. Alternatively, drugs may be applied when acute bleeding was effectively stopped without the use of endoscopic means. Endoscopic sclerotherapy and surgery have no place in the primary prophylaxis of variceal hemorrhage in patients who have not bled before. Prevention of the first bleed is clearly the field for beta-blockers or nitrates. The role of banding ligation in this situation remains to be defined.