The management of variceal bleeding: Past, present and future

The basic principles of managing variceal bleeding have changed little in t he last fifty years. Fluid resuscitation, efforts to induce intra-variceal thrombosis, and treatments to reduce portal pressures remain the keys to su ccessful therapy. However, the last decade has seen the introduction of new modalities which have improved treatment efficacy and safety. Octreotide a nd, at many institutions, terlipressin have supplanted intravenous vasopres sin as acute pharmacologic therapy for variceal bleeding. Endoscopic manage ment of variceal bleeding now includes endoscopic variceal ligation in addi tion to the widely practiced endoscopic sclerotherapy. Placement of transju gular intrahepatic portosystemic shunts has been proven to be a reliable me ans of emergently inducing a reduction in portal pressure and stopping vari ceal hemorrhage. In the out-patient setting, therapy with non-selective bet a-blockers, often coupled with oral nitrates, is increasingly accepted as a means of improving portal hypertension and reducing a patient's risk of fi rst hemorrhage or recurrent variceal bleed. This review focuses on the history and evolution of management strategies f or variceal bleeding, discusses the physiologic basis for each type of ther apy, summarizes current treatment approaches, and addresses recent developm ents in the field.