Portal hypertension management.

Injection sclerotherapy is the mainstay of treatment for acute variceal bleeding and for long-term management after a variceal bleed. In those few patients in whom sclerotherapy fails to control acute bleeding, either a surgical shunt or a simple esophageal transection is recommended. A surgical shunt or a more extensive esophagogastric devascularization and transection operation is advocated for the failures of long-term sclerotherapy management. The role of pharmacological agents in acute variceal bleed management remains in question, and the use of propranolol in long-term management, either as an alternative to sclerotherapy or in combination with sclerotherapy, is controversial. The definitive roles of the newly described variceal banding and transjugular intrahepatic porto-systemic shunts (TIPS) procedures have yet to be established. All patients presenting with end-stage liver disease and esophageal variceal bleeding should be evaluated for a liver transplant, although few will qualify. A possible future transplant should be kept in mind when emergency treatment is planned. Any form of prophylactic therapy for patients with esophageal varices that have not yet bled will remain unjustified until those patients at high risk of a first variceal bleed can be identified. The gastric mucosal lesion, portal hypertensive gastropathy, has been underdiagnosed in the past. Although bleeding does occur, it is seldom a major clinical problem. When necessary, bleeding can be controlled by propranolol or a surgical shunt.