Management Esophageal varices		The most serious complication of portal hypertension is bleeding esophageal varices. The well-established management protocol begins with fluid resuscitation. Not only packed RBCs/whole blood, but platelets (thrombocytopenia from hypersplenism) and fresh frozen plasma (coagulopathy from end-stage liver disease) may be needed, as well as vitamin K. Gastric lavage with normal saline is helpful in diagnosis, as well as improving visualization for the subsequent endoscopy. Bleeding may be controlled by a number of methods. Sclerotherapy involves injection of a sclerosing substance, like ethanol or ethanolamine, into the varix. Endoscopic ligation of varices with elastic bands can be accomplished in patients greater than 1 year of age. Pharmacologic treatment with vasoconstrictors (vasopressin or octreotide) or vasodilators (betablockers) is also commonly used, especially in combination with sclerotherapy or ligation. In the child with esophageal bleeding that is uncontrolled by the above measures, emergency balloon tamponade may be necessary. Either the Linton tube (patients < 40 kg) or the Sengstaken-Blakemore tube (> 40 kg) shown at the right can stop esophageal bleeding in up to 90% of patients. However, their use requires considerable expertise and, even in the most experienced hands, carries the risks of aspiration, airway obstruction, esophageal rupture and ulcers. The child must be intubated and sedated first. In any case, they can only be left in place for 12-24 hours. As such, although potentially life-saving, they are only a temporary measure. Even in cases where the bleeding is controlled by the usual methods, the risk of rebleeding is close to 50%. And, of course, these treatments of esophageal bleeding do nothing to decrease the portal hypertension causing it. Portosystemic shunts or liver transplantation are the only methods that definitively treat the portal hypertension itself. Return to top of page