The management of variceal bleeding: past, present and future

The basic principles of managing variceal bleeding have changed little in the last fifty years. Fluid resuscitation, efforts to induce intra-variceal thrombosis, and treatments to reduce portal pressures remain the keys to successful therapy. However, the last decade has seen the introduction of new modalities which have improved treatment efficacy and safety. Octreotide and, at many institutions, terlipressin have supplanted intravenous vasopressin as acute pharmacologic therapy for variceal bleeding. Endoscopic management of variceal bleeding now includes endoscopic variceal ligation in addition to the widely practiced endoscopic sclerotherapy. Placement of transjugular intrahepatic portosystemic shunts has been proven to be a reliable means of emergently inducing a reduction in portal pressure and stopping variceal hemorrhage. In the out-patient setting, therapy with non-selective beta-blockers, often coupled with oral nitrates, is increasingly accepted as a means of improving portal hypertension and reducing a patient's risk of first hemorrhage or recurrent variceal bleed. This review focuses on the history and evolution of management strategies for variceal bleeding, discusses the physiologic basis for each type of therapy, summarizes current treatment approaches, and addresses recent developments in the field.