Pathophysiology and treatment of variceal hemorrhage

Portal hypertension results from increases in portal flow and portal vascular resistance. Factors increasing portal blood flow are predominantly humoral. Resistance to portal flow has a fixed component due to distortion of the vasculature by cirrhotic nodules and a variable component that is related to vasoactive substances. Varices result from an increase in portal pressure. Factors predicting the risk of variceal bleeding include continued alcohol use, poor liver function, large varices, and red wale markings on varices at endoscopy. Octreotide is probably the drug of choice for pharmacologie management of bleeding esophageal varices. Propranolol has an established role in the prevention of variceal hemorrhage, and avariceal band ligation may be the preferred endoscopie technique. Transjugular intrahepatic portosystemic shunts have emerged as an important treatment for patients in whom pharmacologie and endoscopie therapies have failed and are an effective bridée to liver transnlantation.