Review article
Varices and Variceal Hemorrhage in Cirrhosis: A New View of an Old Problem

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The management of portal hypertension in cirrhosis has evolved over time, leading to improvements in the care and survival of patients with varices and variceal hemorrhage, particularly in patients who achieve a significant reduction in portal pressure. In addition to better treatment strategies and improved therapeutic options, the issue of risk stratification has become essential to identify different patient subpopulations that require a different treatment. We now recognize that the management of varices and variceal hemorrhage must be taken in the context of other complications of cirrhosis (ascites, encephalopathy, jaundice) and that the goals of therapy should be based on the presence of such complications. Evolving knowledge of the predominant pathophysiological mechanisms at each of the stages of cirrhosis also has evolved and will continue to lead to improvements in therapy. This review focuses on the management of varices and variceal hemorrhage with respect to refinements in the risk stratification of patients with cirrhosis.

Section snippets

Clinical Settings

Therapy of varices and variceal hemorrhage now is stratified depending on the different clinical stages in the natural history of portal hypertension,12, 13 as follows: (1) the patient with compensated cirrhosis without clinically significant portal hypertension; (2) the patient with compensated cirrhosis with clinically significant portal hypertension who has not yet developed varices; (3) the patient with cirrhosis and clinically significant portal hypertension with gastroesophageal varices

Conclusions

Marked advances in the knowledge of portal hypertension over the past decades have resulted in the introduction of new effective treatments that have led to a significant improvement in the prognosis of portal hypertension. In parallel, major advances in the development of prognostic markers have allowed for risk stratification and redefinition of end points. We now recognize that management of patients at different prognostic stages is different, resulting in a more personalized approach to

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    Conflicts of interest The authors disclose no conflicts.

    Funding Supported by National Institutes of Health grants P-30DK 034989 (G.G.T.). The Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas is supported by the Instituto de Salud Carlos III (J.B.). Also supported in part by a grant from the Instituto de Salud Carlos III (PI13/00341) in a program co-funded by European Regional Development Fund (ERDF), European Union (J.B.).

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