Variceal Bleeding

Opinion statement Primary prophylaxis: Patients with cirrhosis who have esophageal varices but who have never had a bleeding episode may be treated medically or endoscopically. Without treatment, approximately 30% of cirrhotic patients with varices bleed and this risk is reduced by approximately 50% with therapy. Medical therapy includes nonselective beta blockers with or without nitrates. Compliance and side effects limit efficacy. Primary prophylaxis with endoscopic sclerotherapy is not warranted because of evidence suggesting that complications outweigh benefits. Studies of endoscopic therapy with ligation (endoscopic banding) demonstrate that in select patients (those with large varices), endoscopic banding may reduce the risk of first bleeding episode when compared with propranolol. Patients with large varices may benefit from a combination of banding with nonselective beta blockers. Secondary prophylaxis: After an initial variceal bleed, the risk of a second bleed is high and therapy is warranted to reduce the risk of rebleeding. The options are similar to those for primary prophylaxis, and in addition to medical and endoscopic therapy, transjugular intrahepatic portosystemic shunts (TIPS) and surgical shunts are therapeutic options. The combination of endoscopic therapy with medical therapy is the initial approach to prevent variceal rebleeding. Endoscopic banding is preferred to sclerotherapy because banding is associated with lower bleeding rates and fewer complications. TIPS is useful in cases refractory to endoscopic therapy or in uncontrolled variceal hemorrhage. Surgical shunts are typically reserved for patients in whom TIPS cannot be performed for technical reasons or for well-compensated cirrhotic patients. Acute variceal bleeding: Acute bleeding from esophageal varices requires an endoscopic evaluation and therapeutic intervention. Technically, endoscopic banding may not be possible because of limited visualization from bleeding and sclerotherapy is used because it is easier to perform in this setting. A continuous intravenous drip of octreotide should be initiated if variceal bleeding is suspected. If variceal bleeding cannot be controlled, then a Minnesota tube or Sengstaken-Blakemore tube should be placed by someone with experience. TIPS is effective rescue therapy for controlling acute variceal hemorrhage in circumstances when other methods fail.     

Transjugular intrahepatic portosystemic shunt for the management of acute variceal hemorrhage

Acute variceal hemorrhage,a life-threatening condition that requires a multidisciplinary approach for effective therapy,is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy,the presence of large esophageal varices with recent stigmata of bleeding,or fresh blood visible in the stomach with no other source of bleeding identified.Transfusion of blood products,pharmacological treatments and early endoscopic therapy are often effective;however,if primary hemostasis cannot be obtained or if uncontrollable early rebleeding occurs,transjugular intrahepatic portosystemic shunt(TIPS)is recommended as rescue treatment.The TIPS represents a major advance in the treatment of complications of portal hypertension.Acute variceal hemorrhage that is poorly controlled with endoscopic therapy is generally well controlled with TIPS,which has a 90%to 100%success rate.However,TIPS is associated with a mortality of 30%to 50%in such a setting.Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy failure,before the clinical condition worsens.Furthermore,admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively.This review article discusses initial management and then focuses on the specific role of TIPS as a primary therapy to control acute variceal hemorrhage,particularly as a rescue therapy following failure of endoscopic approaches.     

Current management of esophageal varices

Opinion statement Acute variceal hemorrhage is the most lethal complication of cirrhosis. The reported mortality rate from a first episode of variceal hemorrhage is 17% to 57%. Management of varices can be categorized into three phases: 1) prevention of initial bleeding, 2) management of acute bleeding, and 3) prevention of rebleeding. Modalities for treatment include pharmacologic, endoscopic, and shunt therapy. For the prevention of first variceal hemorrhage, cirrhotic patients should undergo endoscopy to identify patients with large varices. Priority for screening for varices should be given to patients with low platelet count, splenomegaly, and advanced cirrhosis. Once large varices are identified, patients should be started on β-blocker therapy, which reduces the risk of bleeding by 50%. If pharmacologic therapy is not tolerated or contraindicated, endoscopic band ligation should be performed, and surveillance of varices should be performed every 6 months thereafter. Shunt procedures are not indicated due to their higher rates of complications compared with medical therapy. For the management of acute variceal hemorrhage, patients should be started on prophylactic intravenous antibiotics and intravenous octreotide. Endoscopy should be performed to diagnose and treat variceal hemorrhage. Band ligation appears to be as effective as sclerotherapy, but with less complications. If hemostasis is not achieved, balloon tamponade can be used as a bridge to definitive therapy, which in this case would be a transjugular intrahepatic portosystemic shunt (TIPS). If TIPS is unavailable, a surgical shunt is indicated. Once an episode of acute bleeding has been controlled, variceal eradication is best accomplished with repeat band ligation every 10 to 14 days until varices are obliterated. Prevention of recurrent bleeding can be achieved with β-blocker therapy. The addition of isosorbide mononitrate further reduces recurrent bleeding. This combination pharmacologic therapy has been shown to be superior to sclerotherapy and may be superior to band ligation. However, side effects of combination pharmacologic therapy may limit its effectiveness. Band ligation is preferred to sclerotherapy when considering endoscopic therapy due to less complications and lower cost. Surgical shunts should be used for prevention of rebleeding in patients who do not tolerate or are noncompliant with medical therapy and who have relatively preserved liver function. TIPS should be reserved for patients who have poor liver function and who have failed medical therapy.     

Do we need endoscopic sclerotherapy of oesophageal varices or the last turn off the light

For the primary prophylaxis of variceal bleeding endoscopic band ligation has been shown to be as effective as non-selective beta-blockers (carvedilol), but variceal injection sclerotherapy is not generaly recommended in this setting because of higher rate of complications and lower effect in reducing either bleeding or mortality. Endoscopic management of acutely bleeding gastroesophageal varices includes injection sclerotherapy, rubber band ligation, and variceal obturation with tissue adhesives. Variceal injection sclerotherapy remains a quick, simple and cheap technique for the control of active bleeding from esophageal varices, but is associated with more rebleeding than variceal band ligation, which is now preferred also for lower rate of complications. Endoscopic sclerotherapy has increasingly been replaced by ligation also in secondary prophylaxis of variceal bleeding. The studies showed that band ligation can eradicate varices in fewer sessions, re-bleeding and complications were fewer in comparison with variceal injection sclerotherapy. Because of the reduced efficacy, severe complications, and the high mortality associated with using conventional sclerosants in acute bleeding gastric varices, the technique of injecting tissue adhesives has been studied, described and used despite numerous complications. Endoscopic injection sclerotherapy of esophageal varices remains usable as an oldest method in arresting of this hemorrhage only in rare cases when the band ligation is not available.     

Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices.

The optimal management of ruptured gastric varices in patients with cirrhosis has not been codified yet. The present study reports the use of transjugular intrahepatic portosystemic shunt (TIPS) in patients with refractory gastric variceal bleeding. Thirty-two consecutive patients were included. All had been unresponsive to vasoactive agents infusion, sclerotherapy, and/or tamponade and were considered poor surgical candidates. They were followed-up until death, transplantation, or at least 1 year (median: 509 days; range 4 to 2,230). Hemostasis was achieved in 18 out of 20 patients actively bleeding at the time of the procedure. In the whole sample of 32 patients, rebleeding rates were 14%, 26%, and 31%, respectively at 1 month, 6 months, and 1 year. De novo encephalopathy was observed in 5 (16%) patients. Seven patients experienced complications and consequently 4 of these patients died. TIPS primary patency rates were 84%, 74%, and 51%, respectively, at 1 month, 6 months, and 1 year. For the same periods of time, survival rates were 75%, 62%, and 59%. These results suggest that TIPS can be used in cirrhotic patients with refractory gastric variceal bleeding and are effective in achieving hemostasis as well as in preventing rebleeding.     

Current use of transjugular intrahepatic portosystemic shunts

The principal indication for transjugular intrahepatic portosystemic shunts (TIPS) continues to be rescue therapy for variceal hemorrhage that cannot be controlled by endoscopic or medical therapy. TIPS provide no survival advantage in prevention of rebleeding or refractory ascites. The indications for TIPS continue to expand, however, especially for Budd-Chiari syndrome and hydrothorax. Other more novel indications include bleeding portal hypertensive gastropathy or ectopic varices, Budd-Chiari syndrome, veno-occlusive disease, hepatorenal syndrome, hepatopulmonary syndrome, hepatocellular carcinoma, and polycystic liver disease. Great strides have been made recently in models to predict mortality and complications following TIPS placement. Graft stents hold promise based on early studies. Finally, complications are common and may be life threatening.     

Endoscopic injection sclerosis in bleeding gastric varices

Ninety-two consecutive, nonrandomized patients with bleeding varices were prospectively studied using sclerotherapy to control and prevent rebleeding. During this study, nine patients with gastric variceal bleeding were identified. A gastric variceal subset is defined and represents a 10% incidence in this series. All patients presented with indexed gastric bleeding varices that subsequently accounted for 34 bleeding sessions. The units of blood per rebleeding episode, hospital days, cost, and outcome were markedly different from the esophageal variceal groups. Initial management of indexed bleeding episodes by sclerotherapy and Sengstaken-Blakemore tubes were comparable; however, the number of rebleeding episodes was much higher. There was poor control of rebleeding with an associated higher rebleeding mortality and complications secondary to repeated sclerotherapy and Sengstaken-Blakemore tube use. In 37% of the patients, rebleeding was the direct result of gastric ulcerations at the endoscopic injection sclerotherapy site. The survival curve of this group was much lower than esophageal variceal bleeders. Endoscopic injection sclerotherapy in patients with bleeding gastric varices offers only temporary control of bleeding, and the high incidence of severe early rebleeding requires consideration of alternative methods for management or modified sclerotherapy techniques.     

Portal hypertensive bleeding

Portal hypertension bleeding is a common and serious complication of cirrhosis. All patients with cirrhosis should undergo endoscopy and be evaluated for possible causes of current or future portal hypertensive bleeding. Possible causes of bleeding include esophageal varices, gastric varices, and PHG. Patients with esophageal varices at high risk of bleeding should be treated with nonselective beta-blockers for primary prevention of variceal hemorrhage. HVPG measurements represent the optimal way to monitor the success of pharmacologic therapy. EVL may be used in those with high-risk varices who do not tolerate beta-blockers. When active bleeding develops, simultaneous and coordinated attention must be given to hemodynamic resuscitation, prevention and treatment of complications, and active control of bleeding. In cases of acute esophageal variceal (Fig. 5) and PHG bleeding, terlipressin, somatostatin, or octreotide should be started. Endoscopic treatment is provided for those with bleeding esophageal varices. If first-line therapy fails, TIPS or surgery may need to be performed. Unlike esophageal variceal or PHG bleeding, there is no established optimal treatment for gastric variceal bleeding. Individual and specific treatment modalities for acute gastric variceal bleeding must be calculated carefully after considering side effects.     

Nonsurgical treatment of variceal bleeding

Opinion statement Patients with cirrhosis, especially those who have a platelet count of less than 100,000, who are considered compliant, and have no contraindications to beta-blocker therapy, should have a screening endoscopy to ascertain the presence of esophageal varices. Patients with medium to large esophageal varices who are appropriate candidates should be placed on a nonselective beta-blocker (propranolol hyrdochloride, nadolol, timolol maleate) for the prevention of initial variceal hemorrhage. Patients presenting with acute variceal hemorrhage, as determined endoscopically, should be treated with a combination of vasoactive drugs and endoscopic therapy (sclerotherapy or variceal ligation) for the control of acute variceal bleeding and the prevention of early rebleeding. Transjugular intrahepatic portosystemic shunt (TIPS) should be reserved for failures of initial medical therapy. After successful control of initial variceal bleeding is reached, the rebleeding rate approaches 70% in most studies, with the highest risk period being in the first 6 months after control of the index bleed is obtained [1]. Therefore, all patients should be placed on therapy to prevent recurrent variceal bleeding. Options include pharmacologic therapy, endoscopic therapy, and combinations of endoscopic and pharmacologic therapy. TIPS, surgical shunts, and liver transplantation should be reserved for special circumstances and in general, should only be considered for failures of initial medical therapy.     

Transjugular intrahepatic portosystemic shunts and portal hypertension-related complications

Portal hypertension(PH)plays an important role in the natural history of cirrhosis,and is associated with several clinical consequences.The introduction of transjugular intrahepatic portosystemic shunts(TIPS)in the 1980s has been regarded as a major technical advance in the management of the PH-related complications.At present,polytetrafluoroethylene-covered stents are the preferred option over traditional bare metal stents.TIPS is currently indicated as a salvage therapy in patients with bleeding esophageal varices who fail standard treatment.Recently,applying TIPS early(within 72 h after admission)has been shown to be an effective and life-saving treatment in those with high-risk variceal bleeding.In addition,TIPS is recommended as the second-line treatment for secondary prophylaxis.For bleeding gastric varices,applying TIPS was able to achieve hemostasis in more than 90%of patients.More trials are needed to clarify the efficacy of TIPS compared with other treatment modalities,including cyanoacrylate injection and balloon retrograde transvenous obliteration of gastric varices.TIPS should also be considered in bleeding ectopic varices and refractory portal hypertensive gastropathy.In patients with refractory ascites,there is growing evidence that TIPS not only results in better control of ascites,but also improves long-term survivalin appropriately selected candidates.In addition,TIPS is a promising treatment for refractory hepatic hydrothorax.However,the role of TIPS in the treatment of hepatorenal and hepatopulmonary syndrome is not well defined.The advantage of TIPS is offset by a risk of developing hepatic encephalopathy,the most relevant postprocedural complication.Emerging data are addressing the determination the optimal time and patient selection for TIPS placement aiming at improving long-term treatment outcome.This review is aimed at summarizing the published data regarding the application of TIPS in the management of complications related to PH.     

TIPS in Variceal Bleeding: New and Old Indications

Variceal bleeding is one of the most dreaded complications of cirrhosis and its occurrence is associated with significant morbidity and mortality. During the past 30 years preventative therapies have reduced the risk of the first variceal bleed. Once variceal bleeding occurs use of pharmacologic and endoscopic therapies prevent rebleeding in most patients. The existing recommendations are that TIPS only be used in those patients who fail medical therapy. We reviewed recent literature focusing on the role of early TIPS in management of acute variceal hemorrhage and prevention of re-bleeding.     

Therapy and prevention of hemorrhage from esophageal varices

Management of variceal hemorrhage includes emergency treatment of bleeding esophageal varices and prophylactic treatment for the prevention of first bleeding or rebleeding. Endoscopic injection sclerotherapy appears to be the most effective therapeutic option to control acute variceal hemorrhage. When sclerotherapy fails or cannot be performed a Sengstaken-Blakemore tube can be used. Supportive treatment is provided by vasodilator or vasoconstrictor therapy. At present, operative treatment modalities such as portosystemic shunts or esophageal transection are secondary to sclerotherapy or balloon tamponade. The probability of recurrent variceal hemorrhage after a first bleeding is 70%. This necessitates preventive measures such as endoscopic sclerotherapy, beta-blockade, or surgical procedures. Meta-analysis of randomised controlled trials indicates that sclerotherapy appears to reduce the number of episodes of recurrent variceal hemorrhage better than other prophylactic treatments and to improve survival. Chronic sclerotherapy may be the procedure of first choice in patients with good liver function when elective shunt surgery is provided for those who have recurrent bleeding despite sclerotherapy. The role of beta-blockade in the prevention of recurrent bleeding remains to be clearly defined. Prevention of first esophageal bleeding by invasive treatment modalities could reasonably only be performed in patients with high bleeding risk, which, however, cannot be defined accurately at present. The use of beta-blockers in the prevention of first variceal hemorrhage should be restricted to clinical trials.     

The use of TIPS in chronic liver disease

The development of cirrhosis and portal hypertension in the natural history of chronic liver disease is associated with many complications. A transjugular intrahepatic portosystemic stent shunt (TIPS) is a metal prosthesis that has been shown to be very effective in lowering sinusoidal portal pressure, and therefore is effective in the management of complications of cirrhosis, especially those related to portal hypertensive bleeding and sodium and water retention. In patients with acute variceal bleeding not responding to pharmacologic and endoscopic treatments, a reduction of the hepatic venous pressure gradient to < 12 mmHg or by > 20% with TIPS has been shown to be effective in controlling the acute bleed and in preventing rebleeding. For stable patients whose acute variceal bleed is controlled, TIPS is equal to combined beta-blocker and band ligation in the prevention of recurrent variceal bleed. TIPS is also more effective than large volume paracentesis in the control of refractory ascites, and may confer a survival advantage over repeated large volume paracentesis. TIPS has also been used in the management of other complications related to portal hypertension including ectopic varices, hepatic hydrothorax, and hepatorenal syndrome with some success, but experience is still rather limited. Miscellaneous uses include treatment of Budd Chiari Syndrome, portal hypertensive gastropathy and hepatopulmonary syndrome. Careful patient selection is vital to a successful outcome, as patients with severe liver dysfunction tend to die post-TIPS despite a functioning shunt. All patients who require a TIPS for treatment of complications of cirrhosis should be referred for consideration of liver transplant.     

Efficacy of balloon tamponade in treatment of bleeding gastric and esophageal varices

The efficacy and complications of esophageal tamponade as the first procedure in the routine management of acute variceal hemorrhage were evaluated in 151 consecutive bleeding episodes treated at a specialized unit. The Sengstaken-Blakemore tube was employed in the 118 cases in which emergency endoscopy demonstrated bleeding esophageal varices, and the Linton-Nachlas balloon in the 33 cases with bleeding from gastric varices. Hemostasis lasting at least 24 hr was obtained in 91.5% of cases treated with the Sengstaken-Blakemore balloon and in 88% of those treated with the Linton-Nachlas balloon. Permanent hemostasis was obtained in 47.7% of all cases. The only severe complication noted in these 151 episodes of bleeding treated by tamponade was pulmonary aspiration, which was detected in 10% of cases. This complication was related to the presence and degree of encephalopathy (P less than 0.001) and was prevented by orotracheal intubation prior to tamponade. These results indicate that balloon tamponade continues to be a reliable and valuable method to arrest bleeding from esophagogastric varices.     

Pharmacologic therapy for gastrointestinal bleeding due to portal hypertension and esophageal varices

Cirrhosis results in portal hypertension in many patients. The major complications of portal hypertension include development of ascites and esophageal or gastric varices. Varices lead to hemorrhage and death in a significant proportion of patients. This review focuses on the pharmacologic approach to management of portal hypertension in patients at risk of variceal hemorrhage, or those who have already had variceal bleeding. Pharmacologic therapy is used for 1) primary prevention of bleeding, 2) management of acute bleeding, and 3) prevention of recurrent bleeding (secondary prophylaxis). For acute esophageal variceal hemorrhage, a variety of pharmacologic agents are used, including somatostatin, octreotide, vapreotide, lanreotide, terlipressin, and vasopressin (with nitrates). For primary and secondary prevention of esophageal variceal hemorrhage, a-blockers remain the mainstay therapy.     

A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices

Gastric varices (GV) occur in 20% of patients with portal hypertension either in isolation or in combination with esophageal varices (EV). There is no consensus for optimum treatment of GV and because they comprise an inhomogeneous entity, accurate classification is vital to determine the appropriate management. Gastroesophageal varices (GOV) are classified as GOV1 (EV extending down to cardia or lesser curve) or GOV2 (esophageal and fundal varices). Isolated gastric varices (IGV) may be located in the fundus (IGV1) or elsewhere in the stomach (IGV2). GV possibly bleed less frequently than EV, but GV bleeding is typically difficult to control, associated with a high risk for rebleeding, and high mortality. Fundal varices, large GV (>5 mm), presence of a red spot, and Child's C liver status are associated with a high risk for bleeding. GOV1 have a much lower risk for bleeding. A portosystemic pressure gradient of > or =12 mm Hg is not necessary for GV bleeding, probably related to the high frequency of spontaneous gastrorenal shunts in these patients. GOV1 should be treated as for EV. First-line treatment of bleeding fundal varices is endoscopic variceal obturation. TIPS is currently second-line acute treatment and is used for prevention of rebleeding. The role of some newer interventional radiologic techniques requires further appraisal. This review describes the pathophysiology, diagnosis, natural history, endoscopic, and interventional radiologic treatment options for GV.     

Prospective validation of the Rockall risk scoring system for upper GI hemorrhage in subgroups of patients with varices and peptic ulcers

OBJECTIVES: The Rockall risk assessment score was devised to allow prediction of the risk of rebleeding and death in patients with upper GI hemorrhage. The score was derived by multivariate analysis in a cohort of patients with upper GI hemorrhage and subsequently validated in a second cohort. Only 4.4% of patients included in the initial study had esophageal varices, and analysis was not performed according to the etiology of the bleeding. Our aim was to assess the validity of the Rockall risk scoring system in predicting rebleeding and mortality in patients with esophageal varices or peptic ulcers. METHODS: Admissions (n = 358) over 32 months to a single specialist GI bleeding unit were scored prospectively. The distribution of episodes of rebleeding and mortality by Rockall score were statistically analyzed using Fisher's exact test with 99% CIs calculated using a Monte Carlo method. The Child-Pugh score was determined in patients with esophageal varices. RESULTS: The Rockall score was predictive of both rebleeding and mortality in patients with variceal hemorrhage (both ps < 0.0005), as was the Child-Pugh score (p = 0.001 and p < 0.0005, respectively). The initial Rockall score was predictive of mortality in patients with peptic ulcers (p = 0.01), although the complete score was not (p > 0.05). The complete score did, however, predict rebleeding in these patients (p = 0.001). CONCLUSION: This is the first study to validate the Rockall score in specific subgroups of patients with esophageal varices or peptic ulcers and suggests that it is particularly applicable to variceal hemorrhage.     

Transjugular intrahepatic portosystemic shunt in the management of complications of portal hypertension

Transjugular intrahepatic portosystemic shunt (TIPS) is a commonly used approach for managing many complications of portal hypertension. It is an attractive option due to its relative ease of creation (> 90% success rate) and the availability at most hospitals of an interventional radiologist capable of performing the procedure. TIPS is the preferred approach to control acutely bleeding esophageal or gastric varices that cannot be controlled with medical management. It is also now preferred to surgical shunts for preventing rebleeding in patients who rebleed despite adequate medical management. TIPS is more effective than large-volume paracentesis in controlling refractory cirrhotic ascites, with possibly a slight survival benefit but also increased encephalopathy. TIPS should be used to control refractory ascites in patients who cannot be managed with large-volume paracentesis. The role of TIPS in the treatment of hepatorenal syndrome is unclear; currently only patients with type 2 hepatorenal syndrome should be considered candidates for TIPS.     

ENDOSCOPIC SCLEROTHERAPY FOR ESOPHAGO-GASTRIC VARICES: A CRITICAL REAPPRAISAL

Amongst the many non-surgical techniques for the treatment of variceal bleeding, endoscopic sclerotherapy (EST) has shown great promise. EST can successfully obliterate esophageal varices and prevent variceal rebleeding. It is also very effective in the control of active bleeding from esophageal varices. The technique of EST is simple and can be carried out with a conventional, forward viewing, flexible endoscope and a teflon injector. Weekly intravariceal injections of an aqueous sclerosant are prefer-rable. Though complications of EST in experienced hands are low, prophylactic EST at present should be advocated only to patients at high risk of bleeding. While controversy exists, most reports indicate that EST improves survival of patients with portal hypertension who have bled from esophageal varices. With regular follow-up endoscopics, recurrence of varices and bleeding from them can be substantially reduced. Sclerotherapy may successfully obliterate gastric varices in some patients either following EST for esophageal varices or by direct gastric variceal injections. For the long-term management of portal hypertension, combination of pharmacotherapy before as well as after eradication of esophageal varices, needs proper evaluation.     

An 8-year prospective experience with balloon tamponade in emergency control of bleeding esophageal varices

The use of balloon tamponade in the emergency control of bleeding from esophageal varices is controversial. This paper reports a prospective study over an 8-year period in which balloon tamponade has been the sole means employed for the early control of bleeding varices. During 1972–1980 all patients referred to Prince Henry's Hospital with upper gastrointestinal bleeding were admitted to a special unit. Ninety-one had bleeding esophageal varices, and 17 were admitted on one or more occasions for bleeding for a total of 132 admissions. After early endoscopy, balloon tamponade was used during 103 of these admissions with failure to control bleeding on six occasions; five of these patients died from hemorrhage and the sixth recovered after emergency portacaval shunt. Another patient died from rebleeding not treated by tamponade. Reinsertion of the balloon for rebleeding was necessary on 28 occasions with successful control in all cases. Balloon tamponade was not used during 29 admissions because bleeding had ceased or the patient was considered to have terminal liver disease. In this group there were four deaths from severe liver disease and hemorrhage. Balloon tamponade was used in 78% of admissions and controlled bleeding in more than 90% of patients. This suggests that tamponade may be the method of choice for early control of bleeding from esophageal varices.