The management of active variceal bleeding.

A systematic review of available treatments for controlling active variceal bleeding provides important guidelines for choosing an overall strategy. The initial prerequisite of a diagnostic endoscopy provides the opportunity for early intervention with local endoscopic techniques, such as injection sclerotherapy, direct intravariceal injection of tissue adhesives and banding ligation of varices. This approach currently represents the optimal strategy. If the endoscopic expertise is not available, the use of vasoactive drugs may provide temporary control of bleeding while allowing time for more definitive treatment. Vasopressin and its analogues are the most widely used vasoactive drugs, but somatostatin holds promise. In view of the systemic haemodynamic complications associated with vasopressin (and probably glypressin), these drugs should be given in combination with nitrates. Balloon tamponade remains an important alternative for patients in whom massive, life-threatening haemorrhage has occurred. Surgical techniques, such as shunting and devascularisation, are increasingly reserved for the management of variceal bleeding that endoscopic therapy has failed to control.