Variceal hemorrhage is a potentially life-threatening complication of cirrhosis and portal hypertension, with mortality exceeding 50% in severe or advanced liver disease in acute variceal hemorrhage. Pharmacologic therapy has included infusions of vasopressin, glypressin (long-acting analogue), somatostatin, and octreotide. Vasopressin and glypressin reduce portal pressure by splanchnic arteriolar vasoconstriction whereas somatostatin and octreotide lower portal pressure by decreasing hepatic blood flow.

Controlled trials however have not unequivocally established the efficacy of these agents; meta-analysis suggests their positive role in the management. The benefits of somatostatin and octreotide are less certain from the disparate effects on cessation of bleeding in controlled studies. Endoscopic sclerotherapy and variceal ligation have comparable benefit and are independently effective in the control of active variceal bleeding, although fewer complications have been noted with variceal ligation.

Each treatment has its advantages. Sclerotherapy can be accomplished quickly during active bleeding and large varices can be ligated easily without risk of esophageal injury from sclerosant injection. Transjugular intrahepatic portalsystemic shunt (TIPS) avoids the surgical morbidity in patients with advanced liver disease, is effective in portal decompression, particularly in patients requiring control of bleeding prior to liver transplantation, and may not be a suitable option for well-compensated patients. Shunt stenosis in about 50% may favor the performance of portacaval or distal splenorenal shunt as definitive long-term therapy in the nontransplant compensated patient. Risk of hepatic encephalopathy is similar.

Although comparisons of the various treatments have been studied in controlled trials, the benefits and risks of each modality should be weighed in deciding the optimal treatment to control variceal hemorrhage. The expertise at each center in the context of liver transplantation should guide management.