Variceal Bleeding.

Cirrhotic patients should receive an endoscopy. Those with medium to large varices identified by endoscopy should receive beta-blocker therapy. The initial episode of variceal bleeding should be managed with endoscopic therapy to control the acute bleeding and concurrent infusion of octreotide. Portal hypertension and liver disease should be fully evaluated after such an episode, and patients should be started on first-line treatment (endoscopic therapy and pharmacologic therapy) to reduce the risk of further bleeding. Patients who bleed again after first-line therapy, and those with persistent risk factors whose varices are not obliterated by first-line treatment should be considered for second-line treatment, which is variceal decompression with transjugular intrahepatic portosystemic shunt (TIPS) or surgical shunt. For patients with end-stage liver disease, liver transplantation may be the most appropriate treatment option. The management of variceal bleeding leading up to transplantation depends on the severity of the bleeding and available expertise. Minimal therapy to bridge the patient to transplantation is the goal. Devascularization procedures are reserved for patients who are not candidates for decompression because of venous thrombosis.