• endoscopy
• variceal bleeding
• vasoactive drugs

Initial presentation with variceal bleeding is associated with a 20–30% risk of mortality within the first two weeks. Early control of bleeding is paramount and traditionally has taken the form of endoscopic therapy to mechanically reduce variceal blood flow, or vasoactive drugs that decrease splanchnic and/or azygous blood flow. Although sclerotherapy has been shown to reduce bleeding compared with placebo,¹ it results in more frequent adverse events than medical interventions² and has largely been superseded by variceal band ligation. Indeed ligation has been shown to reduce rebleeding and mortality compared with sclerotherapy and is the current gold standard for acute bleeding and secondary prophylaxis.³ A recent evaluation combining the two endoscopic modalities demonstrated no benefit over ligation alone in preventing rebleeding or mortality.⁴

The systematic review by Banares et al suggests a potential benefit from combining vasoactive drugs with endoscopic therapy with improved initial endoscopic control of bleeding and five day haemostasis, albeit with no reduction in mortality. This is a high quality systematic review with assessment of the quality of all included …