Taking the Tension out of Portal Hypertension (Editorial‪)‬

Bleeding from oesophageal varices is the most serious complication of portal hypertension and accounts for most cirrhosis-related deaths. (1) A quarter of high-risk cirrhotic patients with liver decompensation who present with a first major variceal bleed die as a consequence of the bleed. (2) After control of the index bleed, there is a 70% chance of rebleeding with a similar mortality if further effective treatment is not given. (3) Mortality is related to several factors, including failure of rapid control of initial bleeding, early rebleeding, presence and severity of underlying liver disease and functional hepatic reserve. (4) Optimal emergency management requires an efficient and organised team to provide accurate initial assessment of the patient, effective resuscitation, rapid endoscopic diagnosis, successful intervention with control of bleeding, and prevention of early rebleeding as well as the anticipated complications of liver decompensation including spontaneous bacterial peritonitis, progressive liver and renal failure and hepatic encephalopathy. (5) The modern management of acute, persistent variceal bleeding is therefore best accomplished by a skilled, knowledgeable and well-equipped team that can offer the full spectrum of treatment options. (6) The treatment of variceal haemorrhage has evolved markedly in the past decade. (4,7) Substantive advances in the control of acute variceal bleeding have included new and effective drugs, (8) improved endoscopic tools and techniques and refinements in variceal ligation equipment. (9,10) The selective use of radiologically inserted transjugular intrahepatic portosystemic shunts as salvage intervention for intractable bleeding, (11,12) a diminishing role of narrow-diameter polytetrafluoroethylene interposition portacaval shunts (13) and the exponentially increasing demand for liver transplantation (14) in patients with progressive hepatic decompensation and intractable variceal bleeding have further improved survival. Despite these advances in treatment, uncontrolled or recurrent bleeding from varices and the consequences of progressive liver failure remain the commonest causes of early death in cirrhotic patients, (15) emphasising the need for medical staff to act swiftly and decisively as soon as the patient reaches hospital. (16)