<prompt> A patient of chronic liver failure presented with acute variceal bleeding. The BP was 8060 mm Hg. Which of the following is not done?Octreotide infusionEndoscopy bandingTIPSPlatelet transfusion  <response>: Ans. D Platelet transfusionRef: Bailey Loves Short Practice of Surgery 27th Ed; Page No-1164Bleeding Esophageal VaricesLower esophagus being the most common site for variceal bleeding.Diagnosis may be confirmed; if the patient is known to have liver cirrhosis.Esophageal varices will not bleed until the pressure exceeds 12 mm Hg.Variceal haemorrhage is a medical emergency. Patients with massive haemorrhage should be admitted to the intensive treatment unit ITU.ManagementBlood transfusion: Blood volume should be replaced with colloids, plasma expanders and blood transfusions.Correct coagulopathy: Vitamin K is administered 10 mg intravenously, but correction of a coagulopathy will require the administration of fresh-frozen plasma FFP.Esophageal balloon tamponade Sengstaken-Blakemore tubeModified Sengstaken-Blakemore contains four lumens old Sengstaken-Blakemore tube contains 3 tubes. One for aspiration rom stomach one from esophagus, one for esophageal balloon dilation and last one for gastric balloon dilation.The gastric balloon inflated to 250 mL of air and esophageal balloon to a pressure of 40 mm Hg using Air.The potentially lethal complication is accidentally inflating gastric balloon inside the esophagus resulting in perforation of esophagus.Balloons should be temporarily deflated after 12 hours to prevent esophageal necrosis.Pharmacotherapy:Octreotide Long acting analogue of somatostatin and somatostatin are effective like endoscopy.Vasopressin previously used id also effective but nitroglycerine must be given along with it to prevent coronary vessels constriction.Recently Terlipressin is commonly used to arrest bleeding.Endoscopic sclerotherapy or bandingEndoscopic banding is advantageous over sclerotherapy because it doesnt lead to necrosis or ulceration of esophagus but both are equally effective in controlling bleeding.Sclerosants used- Ethanolamine oleate, Cyanoacrylate, and sodium morrhuate or sodium tetradecyl sulphate.Assess portal vein patency Doppler ultrasound or CTTransjugular intrahepatic portosystemic stent shunts TIPSSShort-term bridge to liver transplant.Inserted via IJV by interventional radiologist.Access the portal vein inside the liver via a branch of hepatic vein and dilate the tract to 10 m through which expandable metallic stent is inserted.It is not used as initial therapy but can used if endoscopy and pharmacotherapy fails.It is a type of non-selective shunt between PV and HV.It is an intrahepatic shunt.SurgeryPortosystemic shuntsEsophageal transectionSplenectomy and gastric devascularization 