Prevention of recurrent variceal bleeding

There is a 60 to 80% risk of recurrence of variceal bleeding over a 2 year period with an approximate mortality of 20% per episode. Measures to prevent recurrence include:

• long term injection sclerotherapy - at weekly intervals; varices eventually obliterated by fibrous tissue. Follow up necessary to keep varices ablated.
• surgery - porto-systemic shunting associated with effective prevention of rebleed but significant encephalopathy. Child's grade C has a poor prognosis. Oesophageal transection does not produce encephalopathy but is less effective at preventing rebleeding.
• beta-adrenoceptor blockade, for example oral propanolol, reduces resting pulse by 25% and decreases portal pressure. Portal inflow reduced by decreasing cardiac output (beta-1) and blockade of beta-2 vasodilator fibres on the splanchnic arteries.