Within the short span of half a century, the treatment of variceal bleeding has become
highly differentiated, with multiple treatment options. Pharmacological therapy with
â-blockers is well established for preventing the first variceal bleeding. The utility
of adding a vasodilator to â-blockers needs to be studied further. Octreotide is widely
used as an adjuvant to standard endoscopic treatment to prevent variceal rebleeding,
and the utility of this approach has been validated in several randomized controlled
trials. Band ligation is well established, and its popularity has increased with the
introduction of multiple ligation devices. The technical simplicity and safety of
band ligation has sparked interest in using this technique for primary prophylaxis
of variceal bleeding. However, randomized trials have not shown any advantage for
band ligation over â-blocker therapy, and the high variceal recurrence rate after
band ligation may eliminate any theoretical advantage. A synchronous combination of
band ligation and sclerotherapy has not been shown to improve the results of band
ligation alone, but a metachronous approach using sclerotherapy to treat recurrent
varices after band ligation has shown beneficial results. Histoacryl remains the best
treatment option for gastric varices, but band ligation and loop ligation have shown
promising results, and should be considered when Histoacryl is not available. Balloon-occluded
retrograde transvenous obliteration is a new radiological modality for gastric varices,
and one that sounds promising. TIPS is well established as an alternative to elective
endoscopic treatment. Compared with endoscopic treatment, TIPS has been shown to improve
the survival rate in one randomized trial. However, the cost and complications of
TIPS have restricted its use. The use of endoscopic ultrasound for Doppler studies
of blood flow in portal hypertension is currently investigational, but it may gain
a role in selecting the optimal treatment approach for the individual patient.
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M.D. M.D. K. F. Binmoeller
K. F. Binmoeller
K. F. Binmoeller
UCSD Medical Center
200 W. Arbor Drive
San Diego, CA 92103-8413
USA
Associate Professor of Medicine and Surgery, Director of Endoscopy
Phone: +1-619-543-2766
Email: kbinmoeller@ucsd.edu
