Review article: the modern management of portal hypertension – primary and secondary prophylaxis of variceal bleeding in cirrhotic patients

Summary Background  Variceal bleeding is a life–threatening complication of liver cirrhosis with a high probability of recurrence. Treatment to prevent first bleeding or rebleeding is mandatory. Aim  To provide an overview of the current knowledge on the best evidence‐based therapeutic options to prevent first or recurrent bleeding from oesophageal varices in patients with cirrhosis. Methods  For the preparation of this narrative review, we sought to analyse randomized controlled trials that examined the efficacy and side effects of pharmacological or endoscopic therapy for the primary and secondary prophylaxis of oesophageal variceal bleeding. Results  Endoscopic band ligation (EBL) and nonselective β‐blockers are both effective in preventing first bleeding. Until more long‐term data are available, nonselective β‐blockers should be the first treatment option because of less severe side effects. EBL is an alternative when β‐blockers are contraindicated or not tolerated. Patient preference may also be considered. For prevention of rebleeding, nonselective β‐blockers (preferably in association with isosorbide‐5‐mononitrate) or EBL are both effective and good alternative treatments. A combination of both treatments may be the best alternative. Conclusions  A great improvement in the prevention of variceal bleeding has emerged over the last years. However, further therapeutic options that combine higher efficacy, better tolerance and fewer side effects are needed.