Portal hypertension (PH), a common complication of
liver cirrhosis, results in development of
esophageal varices. When
esophageal varices rupture, they cause significant upper gastrointestinal
bleeding with mortality rates up to 20% despite state-of-the-art treatment. Thus, prophylactic measures are of utmost importance to improve outcomes of patients with PH. Several high-quality studies have demonstrated that non-selective beta blockers (NSBBs) or endoscopic band
ligation (EBL) are effective for primary prophylaxis of variceal
bleeding. In secondary prophylaxis, a combination of NSBB + EBL should be routinely used. Once
esophageal varices develop and variceal
bleeding occurs, standardized treatment algorithms should be followed to minimize
bleeding-associated mortality. Special attention should be paid to avoidance of overtransfusion, early initiation of vasoconstrictive
therapy, prophylactic
antibiotics and early endoscopic
therapy. Pre-emptive transjugular intrahepatic
portosystemic shunt should be used in all Child C10-C13 patients experiencing variceal
bleeding, and potentially in Child B patients with active
bleeding at endoscopy. The use of
carvedilol, safety of NSBBs in advanced
cirrhosis (i.e. with refractory
ascites) and assessment of hepatic venous pressure gradient response to NSBB is discussed. In the present review, we give an overview on the rationale behind the latest guidelines and summarize key papers that have led to significant advances in the field.