Variceal hemorrhage is a common and devastating complication of portal hypertension and is a leading cause of death in patients with cirrhosis. The management of gastroesophageal varices has evolved over the last decade resulting in improved mortality and morbidity rates. Regarding the primary prevention of variceal hemorrhaging, nonselective β-blockers should be the first-line therapy in all patients with medium to large varices and in patients with small varices associated with high-risk features such as red wale marks and/or advanced cirrhosis. EVL should be offered in cases of intolerance or side effects to β-blockers, or for patients at high-risk for variceal bleeding who have medium or large varices with red wale marks or advanced liver cirrhosis. In acute bleeding, vasoactive agents should be initiated along with antibiotics followed by EVL or endoscopic sclerotherapy (if EVL is technically difficult) within the first 12 hours of presentation. Where available, terlipressin is the preferred agent because of its safety profile and it represents the only drug with a proven efficacy in improving survival. All patients surviving an episode of bleeding should undergo further prophylaxis to prevent rebleeding with EVL and nonselective β-blockers. 1. Introduction Portal hypertension is the main complication of cirrhosis and the gradient between portal pressure and inferior vena cava pressure, the hepatic venous pressure gradient (HVPG), is increased over the normal value of 5？mmHg. Clinically significant portal hypertension is defined as having an HVPG of 10？mmHg or more. Esophageal varices are present in nearly 30% to 40% of patients with compensated cirrhosis and in 60% of those with decompensated cirrhosis [1]. Variceal hemorrhages occur only when there is a clinically significant portal hypertension, defined as HVPG？>？12？mmHg [2]. Variceal hemorrhage is perhaps the most devastating portal hypertension-related complication in patients with cirrhosis, occurring in up to 30% of such individuals during the course of their illness. Moreover, variceal hemorrhage leads to deterioration in liver function and is a common trigger for other complications of cirrhosis, such as bacterial infections or hepatorenal syndrome. The 1-year rate of a first bleeding episode is 5–15% and its risk is defined by variceal size, red signs on the varices, and severity of liver disease in patients [3]. As many as 70% of survivors have recurrent bleeding within 1 year after the index hemorrhage [4]. Although mortality rates of variceal hemorrhage in patients with cirrhosis have
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