LIVER: Edited by Don C. RockeyUpdated strategies in the management of acute variceal haemorrhageEdelson, Jeromea,∗; Basso, Jessica E.a,∗; Rockey, Don C.bAuthor Information aDepartment of Gastroenterology and Hepatology, Brooke Army Medical Center, Fort Sam Houston, Texas bDigestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA Correspondence to Don C. Rockey, MD, Digestive Disease Research Center, 96 Jonathan Lucas Street, CSB, Room 803, Charleston, SC 29425, USA. Tel: +1 843 792 2914; e-mail: [email protected] Current Opinion in Gastroenterology: May 2021 - Volume 37 - Issue 3 - p 167-172 doi: 10.1097/MOG.0000000000000723 Buy Metrics Abstract Purpose of review This article reviews the most recent studies regarding the management of acute esophageal variceal haemorrhage. Recent findings New randomized control trials and meta-analyses confirmed the role of early transjugular intrahepatic portosystemic shunt (TIPS) in the management of acute variceal haemorrhage in Child-Pugh C (10–13) and B patients with active bleeding. A recent randomized controlled trial focused on the duration of vasoactive therapy showed no difference between 2 and 5 days of octreotide. A randomized trial showed decreased use of blood products for the correction of coagulopathy using a thromboelastography-guided approach (vs. conventional parameters) as well as decreased bleeding rates when compared with standard of care. A meta-analysis found that for rescue of variceal bleeding, self-expanding metallic stents were more efficacious and safer than balloon tamponade. In addition, studies showed that Child-Pugh C patients and those with hepatic vein pressure gradient more than 20 were at the highest risk of treatment failure, while model for end-stage liver disease was highly predictive of in-hospital mortality. Summary In patients with severe coagulopathy and uncontrolled bleeding, TEG-based transfusion strategies are recommended. Antibiotics should be used for all cirrhotic patients presenting with upper gastrointestinal bleeding, but should be tailored in accordance to local resistance patterns. Early TIPS for high-risk patients has been shown to have a significant survival benefit. Certain aspects of the management of variceal bleeding remain poorly studied such as the role of early TIPS in Child-B patients as well as strategies for rescue therapy in patients who are not TIPS candidates, and require further investigation. Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.