Variceal bleeding is one of the most feared complications of portal hypertension in patients with cirrhosis due to its deleterious impact on prognosis. Adequate management of patients at risk of developing variceal bleeding includes the prevention of the first variceal bleeding and rebleeding and therefore is crucial in modifying prognosis. The presence of clinically significant portal hypertension is the main factor determining the risk of development of varices and other liver related decompensations; therefore it should be carefully screened for and monitored. Treating patients with clinically significant portal hypertension based on their individual risk of portal hypertension related bleeding undoubtedly improves prognosis. The evaluation of liver hemodynamics and liver function can stratify patients according to their risk of bleeding and are no question useful tools in guiding therapy in an individualized manner. That said, recent data supports the idea that tailoring therapy in accordance with patient characteristics may effectively impact prognosis and increase survival in all clinical scenarios. This review will focus on evaluating the available evidence supporting individual risk characteristics for clinical decision-making and its impact in clinical outcome and survival. In primary prophylaxis, identification and treatment of patients with clinically significant portal hypertension improves decompensation-free survival. In the setting of acute variceal bleeding, the risk of failure and rebleeding can be easily predicted and thus stepping up treatment early during admission in adequate candidates (i. e. pre-emptive TIPS) can increase survival. Stratifying risk for the prevention of recurrent variceal bleeding taking into account liver function and hemodynamic response to non-selective beta-blockers allows tailoring treatment thereby increasing survival and avoiding adverse events.

中文翻译：

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静脉曲张出血的精准医学：我们到了吗？

静脉曲张出血是肝硬化患者门静脉高压症最可怕的并发症之一，因为它对预后有不利影响。对有发生静脉曲张出血风险的患者进行充分管理包括预防首次静脉曲张出血和再出血，因此对于改善预后至关重要。有临床意义的门静脉高压症的存在是决定静脉曲张和其他肝脏相关失代偿发生风险的主要因素；因此，应仔细筛选和监测。根据门静脉高压相关出血的个体风险来治疗具有临床意义的门静脉高压患者无疑会改善预后。肝脏血流动力学和肝功能的评估可以根据患者的出血风险对患者进行分层，毫无疑问是指导个体化治疗的有用工具。也就是说，最近的数据支持这样一种观点，即根据患者特征定制治疗可以有效地影响预后并提高所有临床情况下的生存率。本综述将重点评估支持临床决策的个体风险特征的现有证据及其对临床结果和生存的影响。在初级预防中，识别和治疗具有临床意义的门静脉高压症患者可提高无代偿失调生存率。在急性静脉曲张出血的情况下，失败和再出血的风险可以很容易地预测，因此在入院期间对足够的候选人进行早期治疗（即先发制人的 TIPS）可以提高生存率。考虑到肝功能和对非选择性 β 受体阻滞剂的血流动力学反应，对预防复发性静脉曲张出血的风险分层允许定制治疗，从而提高生存率并避免不良事件。