Bleeding from oesophageal varices is the most common cause of serious gastrointestinal haemorrhage in children. Bleeding may occur at any age, but some patients with varices never bleed.1 The risk of bleeding is not linearly related to portal pressure, but to the size of the varix and the thickness and integrity of its wall.2 Thus varices are most likely to bleed if they project prominently into the oesophageal lumen, if the overlying mucosa is blue, and particularly if there are ‘cherry red spots’ on the varix. Salicylate ingestion used to be recognised as an important precipitant.

The treatment of bleeding oesophageal varices is dependent on the underlying cause. In patients with portal hypertension fromintrahepatic liver disease treatment is dictated by the latter and may determine the need for liver transplantation. Patients with good liver function and bleeding varices can, however, be successfully managed by treatment of their portal hypertension alone. Opinions on the primary management of extrahepatic portal hypertension have long been divided between those who advocate portosystemic shunting and those who favour endoscopic injection sclerotherapy. The results from studies of large series of children undergoing endoscopic injection sclerotherapy have encouraged the widespread acceptance of this technique in children with intrahepatic disease, in whom prognosis is determined more by underlying liver pathology, and in those with portal vein thrombosis or presinusoidal venous obstruction in whom variceal bleeding is the main threat to life.3-5

The management of acute variceal bleeding involves prompt but careful resuscitation. Shock should be corrected by cautious blood transfusion, but over transfusion may increase splanchnic blood flow and precipitate rebleeding. Coagulopathy and severe thrombocytopenia (platelet count less than 50 × …