New Approaches to the Management of Portal Hypertension and Variceal Haemorrhage

Although the development of ascites and hepatic encephalopathy depend partly on the presence of portal hypertension and the associated portasystemic collateral circulation, the most dramatic consequence is variceal rupture, and it is with this situation that this chapter is concerned. Variceal bleeding is unpredictable, with rapid death following a massive single bleed or smaller intermittent bleeds spread over several days or weeks. Haemorrhage may stop spontaneously but recurrence is common and is poorly tolerated in patients with cirrhosis, usually being accompanied by the development of hepatic encephalopathy and other signs of deteriorating liver function. Figures for admission mortality have varied from 19% [1] to 60% [2] in cirrhotic patients presenting with gastrointestinal bleeding and until recently there was little evidence that survival in this group had changed significantly over the last 30 years.