Bacterial infections may be both a consequence and a precipitating event as they can significantly increase portal pressure. In fact, 20 % of patients with AVB may have an active infection at the time of bleeding [9]. Antibiotics significantly reduce the incidence of bacterial infections and improve survival in patients with AVB [10]. Therefore, antibiotic prophylaxis is considered an integral part of therapy in patients with cirrhosis and AVB. Prophylaxis should be instituted as soon as possible as presence of bacterial infection is an independent predictor of failure to control bleeding and death [11].

Aspiration pneumonia is perhaps the most common infection in AVB. Inhalation of blood or gastric content is common in patients with hepatic encephalopathy, especially during hematemesis, upper endoscopy, and esophageal tamponade. Measures to prevent aspiration include monitoring of the neurological status (in specific units with trained nurses), use of a semi-recumbent position (preferably left lateral), and most importantly, orotracheal intubation in patients with hepatic encephalopathy or coma, vomiting copious amount of blood, and those requiring any sedation, i.e., for placement of a balloon tamponade , and/or hemodynamically unstable patients. If aspiration is clinically suspected, the patient should immediately receive appropriate antibiotic treatment. In addition to aspiration pneumonia, patients may develop spontaneous bacterial peritonitis, urinary tract infections, spontaneous bacteremia and nosocomial or community-acquired pneumonia. Enteric pathogens are the most commonly involved microorganisms.

Oral quinolones (norfloxacin 400 mg b.i.d., orally or by nasogastric tube for at least 7 days) are recommended for most patients. Intravenous ceftriaxone (1–2 g daily for 7 days) should be considered in high-risk patients (i.e., those with ascites, severe malnutrition, encephalopathy or serum bilirubin > 3 mg/dL), as well as in hospital settings with high prevalence of quinolone-resistant bacterial infections and in patients on previous quinolone prophylaxis [12].

Nonabsorbable disaccarides (lactulose or lactitol) orally, by nasogastric tube, or in enemas have failed to show any efficacy in the prevention of the development of hepatic encephalopathy [13]. Nevertheless, they are the recommended therapy once hepatic encephalopathy develops [14]. Rifaximin is an effective add-on therapy to lactulose to maintain remission in patients with hepatic encephalopathy [15].

Renal failure is an independent predictor of mortality in AVB. Thus, it is of utmost importance to preserve renal function by replacement of i.v. fluids (avoiding both hypo and hypervolemia) [16]. Administration of diuretics may worsen hypovolemia and nephrotoxic drugs such as aminoglycosides and non-steroidal anti-inflammatory agents (NSAIDs) should be avoided. Acute renal failure may be transient or severe leading to type I hepatorenal syndrome or acute tubular necrosis. Renal function must be monitored with serial measurements of serum creatinine, urea, sodium , potassium, and quantification of daily diuresis.

Tense ascites should be treated because it can cause dyspnea and vomiting as well as increase portal and variceal pressure [17]. Large-volume paracentesis is associated with a significant reduction in portal and collateral pressure, but can be associated with renal failure in up to 18 % of the cases despite albumin infusion. Consequently, small-volume paracentesis (less than 5 L) is recommended during the AVB to reduce portal pressure and preserve renal function [16].

Patients often have some degree of malnutrition which confers a high risk of infection. It is important to start oral feeding as soon as the bleeding episode is controlled (i.e., 24 h after achieving hemostasis).

The use of vasoctive drugs before endoscopy decreases the incidence of active bleeding facilitating endoscopic therapy and further control of bleeding [20, 21]. A randomized controlled trial (RCT) also demonstrated that the early administration of terlipressin , during the transfer to hospital, may improve survival [21]. Experts agree that vasoactive therapy must be maintained for at least 5 days to prevent early rebleeding [22]. However, a recent RCT showed that a 24-h course of terlipressin is as effective as a 72-h course when used as an adjunctive therapy to successful endoscopic band ligation [23]. Vasoactive drugs with proven efficacy and a high safety profile include terlipressin, somatostatin, octreotide, and vapreotide. They should always be used in combination with endoscopic therapy.

Terlipressin, a long-acting synthetic derivative of vasopressin (triglycyl-lysine-vasopressin), has shown to effectively control AVB and decrease transfusion requirements and bleeding-related mortality (18 % reduction vs. placebo) [24, 25]. Experts recommend starting terlipressin at a dose of 2 mg every 4 h (1.5 mg when weight is 50–70 kg and 1.0 mg when it is < 50 kg) with titration to 1 mg/4 h. Terlipressin is a potent vasoconstrictor and therefore it should not be given to patients with ischemic heart disease. Terlipressin has a high safety profile with minor adverse events including abdominal pain and/or diarrhea, pallor and bradycardia in varying degrees immediately following bolus administration [25]. Moreover, terlipressin may induce an acute but reversible reduction in serum sodium concentration [26].

Somatostatin reduces portal pressure by inducing selective splanchnic vasoconstriction without significant systemic effects. Somatostatin has been shown to be as effective as terlipressin both in the control of AVB and in the prevention of early rebleeding [24, 27]. Somatostatin is usually administered as a continuous infusion of 250 mcg/h after an intravenous bolus (250 mcg), which can be repeated if necessary [27]. In a hemodynamic study, patients without a drop of > 10 % of their HVPG with an infusion of 250 mcg/h of somatostatin, were then able to achieve a marked reduction (> 20 %) in portal pressure with a higher dose of 500 mcg/h of somatostatin or the administration of 1 mg of terlipressin [28]. In patients actively bleeding at initial endoscopy an infusion dose 500 mcg/h achieves a higher rate of control of bleeding, lower early rebleeding, reduced mortality (at 1 and 6 weeks) and less transfusion requirements compared with a standard dose of 250 mcg/h [29]. The somatostatin analogues octreotide and vapreotide also improve the results of endoscopic therapy when used in combination with band ligation [30], but have uncertain effects if used alone [24, 31].

Endoscopic therapy , either ES or EBL, is highly effective in the control of AVB with an immediate efficacy in 85–90 % of cases. RCTs that compared both methods in AVB have clearly shown that treatment with EBL and vasoconstrictors is associated with higher efficacy, safety, and improved mortality than ES and vasoconstrictors. Therefore, EBL is considered the endoscopic therapy of choice in AVB. Current guidelines recommend band ligation for AVB, although ES may be used in the acute setting if ligation is technically difficult [6, 32]. As discussed above, placing a nasogastric tube to lavage and empty the stomach together with the use of prokinetic agents may shorten and facilitate endoscopic therapy.