Within the short span of half a century, the treatment of variceal
bleeding has become highly differentiated, with multiple treatment options. Pharmacological
therapy with beta-blockers is well established for preventing the first variceal
bleeding. The utility of adding a
vasodilator to beta-blockers needs to be studied further.
Octreotide is widely used as an adjuvant to standard endoscopic treatment to prevent variceal rebleeding, and the utility of this approach has been validated in several randomized controlled trials. Band
ligation is well established, and its popularity has increased with the introduction of multiple
ligation devices. The technical simplicity and safety of band
ligation has sparked interest in using this technique for primary prophylaxis of variceal
bleeding. However, randomized trials have not shown any advantage for band
ligation over beta-blocker
therapy, and the high variceal recurrence rate after band
ligation may eliminate any theoretical advantage. A synchronous combination of band
ligation and
sclerotherapy has not been shown to improve the results of band
ligation alone, but a metachronous approach using
sclerotherapy to treat recurrent
varices after band
ligation has shown beneficial results.
Histoacryl remains the best treatment option for
gastric varices, but band
ligation and loop
ligation have shown promising results, and should be considered when
Histoacryl is not available. Balloon-occluded retrograde transvenous obliteration is a new radiological modality for
gastric varices, and one that sounds promising.
TIPS is well established as an alternative to elective endoscopic treatment. Compared with endoscopic treatment,
TIPS has been shown to improve the survival rate in one randomized trial. However, the cost and complications of
TIPS have restricted its use. The use of endoscopic ultrasound for Doppler studies of blood flow in
portal hypertension is currently investigational, but it may gain a role in selecting the optimal treatment approach for the individual patient.