All patients should take blockers unless they have contraindications. Surgical management of varices Surgical procedures Patients with good liver function in whom endoscopic management fails or who live far from centres where endoscopic sclerotherapy services are available are candidates for surgical shunt procedures. A successful portosystemic shunt prevents recurrent variceal bleeding but is a major operation that may cause further impairment of liver function. Partial portacaval shunts with 8 mm interposition grafts are equally effective to other shunts in preventing rebleeding and have a low rate of encephalopathy. Oesophageal transection and gastric devascularisation are now rarely performed but have a role in patients with portaland splenic vein thrombosis who are unsuitable for shunt procedures and continue to have serious variceal bleeding despite endoscopic and drug treatment.
Liver transplantation is the treatment of choice in advanced liver disease.
Hepatic decompensation is the ultimate decompressive shunt for portal hypertension and also restores liver function. Most patients with portal hypertension never bleed, and it is difficult to predict who will. Attempts at identifying patients at high risk of variceal haemorrhage by measuring the size or appearance of varices have been largely unsuccessful. Higher rates are reported in patients with left sided portal hypertension due to thrombosis of the splenic vein. Endoscopic control of gastric varices is difficult unless they are located on the proximal lesser curve in continuation with oesophageal varices.