Variceal Bleeding

This chapter focuses on the pathophysiology, management, and prevention of variceal hemorrhage due to gastroesophageal varices caused by cirrhosis-induced portal hypertension. The main factors that determine the likelihood of developing new varices and an increase in size of existing varices, are ongoing hepatic injury, the degree of portosystemic shunting, the portal pressure, and the endoscopic appearance of the varices. Initial resuscitation should aim to control variceal bleeding and prevent early rebleeding, whilst avoiding further deterioration or decompensation of liver disease, acute kidney injury or infection. Thrombin injection should be considered as a possible bridging therapy in acute gastric variceal bleeding not controlled by conventional therapy prior to other definitive treatments. The chapter highlights that whilst mortality from gastroesophageal bleeding has decreased considerably over the last four decades, in part due to better standardization of care and intensive support following acute variceal bleeding, rebleeding rates and long-term mortality remain unacceptably high.