Variceal
bleeding is one of the dreaded complications of
portal hypertension. Patients who have suspected or proven
cirrhosis should undergo diagnostic upper endoscopy to detect medium and large gastro-
esophageal varices. Patients with medium and large gastro-
esophageal varices should be treated with non-selective beta-blockers (
propranolol or
nadolol), and these agents should be titrated to a heart rate of 55 beats per minute or adverse effects. If there are
contraindications to or if patients are intolerant to beta-blockers, it is appropriate to consider prophylactic banding
therapy for individuals with medium-to-large
esophageal varices. When patients who have
cirrhosis present with GI
bleeding, they should be resuscitated and receive
octreotide or other vasoactive agents. Endoscopy should be performed promptly to diagnose the source of
bleeding and to provide endoscopic
therapy (preferably banding). The currently available treatment for acute variceal
bleeding provides hemostasis in most patients. These patients, however, are at significant risk for rebleeding unless secondary prophylaxis is provided. Although various pharmacological, endoscopic, radiological, and surgical options are available, combined pharmacological and endoscopic
therapy is the most common form of secondary prophylaxis.
TIPS is a radiologically placed
portasystemic shunt, and if placed in suitable patients, it can provide effective treatment for patients with variceal
bleeding that is refractory to medical and endoscopic
therapy.