Variceal Bleeding Refractory to Endoscopic Management: Indications and Use of Balloon Tamponade, Interventional Radiology, and Surgical Treatment

In summary, operative therapy presently has a limited role in patients with variceal bleeding. Most patients can be successfully managed with a combination of drug and endoscopic therapy. Portal decompression needs to be considered for those individuals failing these less invasive treatments. Whether TIPS or an operative shunt should be done still remains somewhat controversial. However, because of its better patency over a long period of time, a selective shunt may be the best option for those with good hepatic functional reserve. Liver transplantation can then serve as a salvage therapy if and when hepatic failure ensues. Patients with poor hepatic functional reserve are probably best served by a TIPS as they are likely to die from their liver disease before TIPS occlusion develops. A devascularization operation is the only alternative for patients with diffuse splanchnic venous thrombosis when drug and endoscopic therapy have failed to control bleeding. Finally, there is no single magic bullet for the management of these patients. The thoughtful practitioner realizes that sequential therapies are often necessary and that they may eventually lead to liver transplantation. © 2005 Elsevier Inc. All rights reserved.