Variceal hemorrhage in cirrhosis

INTRODUCTION: Variceal bleeding (VB) is a defining event of decompensation in cirrhosis and remains cause of morbidity and mortality. The presence of other decompensating events determines management and prognosis. AREAS COVERED: This review discusses risk-stratified management and prevention of VB, including acute therapy, indications for transjugular intrahepatic portosystemic shunt (TIPS), and stage-specific primary and secondary prophylaxis. A PubMed/MEDLINE search prioritized trials, meta-analyses, and guidelines. EXPERT OPINION: In patients presenting with VB, standard management consists of vasoconstrictive drugs, antibiotics, and endoscopic variceal ligation (EVL). If bleeding cannot be controlled, TIPS placement should be considered. Recent studies show preemptive TIPS confers survival benefit in patients at high risk of failing standard therapy, defined as Child-Pugh scores 10-13 or 8-9 with active bleeding at endoscopy. In patients whose bleeding is controlled who do not undergo TIPS during the acute episode, secondary prophylaxis consists of nonselective beta-blockers (NSBBs) plus EVL. In patients with ascites, NSBB or EVL is recommended for high-risk varices to prevent first bleeding. In compensated cirrhosis, the goal is to prevent decompensation, including VB, ascites, and hepatic encephalopathy. Therapy targets patients at high risk of decompensation defined by clinically significant portal hypertension using elastography and platelet count. NSBBs, preferably carvedilol, are recommended.