Portal hypertension may be caused by portal venous outflow obstruction, an increased portal venous inflow due to a hyperdynamic circulation or both. Portal venous collaterals usually develop above a threshold portal venous pressure of 10 to 12 mm Hg. Only about one third of patients with esophageal varices eventually bleed. However, the mortality in patients who do bleed is high (around 50%) mostly because patients frequently die prior to hospital admission. Immediate endoscopy for precise location of site of bleeding is essential. Bleeding then may be controlled by drugs which lower portal pressure, balloon-tube tamponade or emergency injection sclerotherapy. Of these therapeutic options sclerotherapy probably has the highest success rate for the acute control of variceal bleeding. It can in addition be combined with the initial endoscopic diagnostic procedure, and repeated injection sclerotherapy can reduce the incidence of recurrent variceal bleeding. Portasystemic shunts, transection and devascularisation operations are nowadays only used in patients in whom repeated sclerotherapy had failed. Beta-blocking agents may be an alternative for long-term management after variceal bleeding, although the results are controversial. The data regarding prophylaxis of first variceal hemorrhage are conflicting. Prophylactic regimens should only be carried out in the form of controlled trials.