The treatment of esophageal varices.

Abstract

The etiology, the geographic variation in pathology, and the level of hepatic reserve all affect the prognosis in patients with bleeding from esophageal varices. Acute variceal bleeding requires emergency treatment. The options include pharmacological therapy, balloon tube tamponade, and urgent sclerotherapy used singly or in combination. Immediate sclerotherapy at the time of the initial diagnostic endoscopy is the preferred treatment. Those in whom sclerotherapy fails should be subjected to more major surgery. Patients presenting after a variceal bleed has been controlled should be considered for definitive long-term treatment. The main options are repeated sclerotherapy, a portosystemic shunt, or a devascularization and transection operation. All patients should be evaluated for liver transplantation prior to therapy. Repeated sclerotherapy is widely recommended, with many groups reserving major surgery as a salvage procedure if sclerotherapy fails. Pharmacological therapy remains under review. Prophylactic treatment prior to a variceal bleed should probably be restricted to controlled trials.