The management of variceal bleeding.

Fastidious resuscitation is essential in the initial management of acute variceal bleeding and requires adequate monitoring. Where endoscopic services are available diagnostic endoscopy should be performed ideally within 4-6 hours of admission and endoscopic therapy with injection sclerotherapy or binding ligation performed. Treatment to prevent early rebleeding will require further endoscopic treatment and possibly adjuvant vasoconstrictor therapy (somatostatin/octreotide or glypressin). Where endoscopy is unavailable vasoconstrictor therapy and/or balloon tamponade should be started prior to transfer to a centre with endoscopic facilities. Treatment failures should be considered for TIPSS or surgery. Gastric varices are better treated endoscopically with bovine or human thrombin than sclerotherapy. For prevention of rebleeding, variceal obliteration with endoscopic band ligation or prophylactic beta blockade are the two optimal treatments, although candidates may be identified for TIPPS if rebleeding recurs. Only beta blockers have so far been shown to be of value as primary prophylaxis.