Prediction of the First Variceal Haemorrhage

255 Although not widely availble when this trial was initiated in 1978, endoscopic treatment (sclerosis and banding) has become the mainstay in most centers for management of the acute variceal bleeder with bleeding control rates in excess of 70% in nearly all series[4,5,6]. Additionally, other effective non-operative therapies such as transjugular intrahepatic portosystemic shunt (TIPS)[7] and intravenous octreotide[4,8] have been introduced since the completion of this trial. Since a TIPS accomplishes portal decom-pression in a manner similar to a surgical shunt, it would be expected to relieve variceal bleeding as well, with potentially less morbidity, especially in high risk patients. Patients treated with TIPS often improve their liver function, but those who deteriorate due to inadequate functional hepatic reserve can be considered for liver transplantation. Unlike patients with surgical shunts, TIPS does not increase, and in fact may decrease the risk of liver transplantation. Since the results of this trial, which enrolled patients from 1978 to 1983 but which was not published until 1994, may have limited relevance to the management of acute variceal bleeding in 1996, the results of an ongoing trial of EPCS versus endoscopic treatment by Orloff's group are eagerly awaited. Will this provide a definitive answer? Probably not, because TIPS is now available for high-risk patients who fail emergency endoscopic treatment. In fact, it is unlikely that any single therapy will ever be uniformly applicable to this heterogeneous group of patients. Now that several effective modalities are available, a thoughtful, individualized approach is essential to obtain optimal results. (1987). Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and acute variceal hemorrhage. N. Engl. J. sclerosis and esophageal balloon tamponade in acute hemorrhage from esophagogastric varices: a pros-pective'controlled randomized trial. medical and surgical management of acute variceal hemorrhage. Am. transjugular intrahepatic portosytemic shunt to control variceal bleeding before liver transplantation.