The current Cape Town management policy for patients with suspected acute variceal bleeding includes vasopressin infusion 0.4 units/minute, and emergency diagnostic endoscopy. Sengstaken balloon tube tamponade is reserved for patients with active variceal bleeding at the time of emergency endoscopy. Only these patients have early emergency sclerotherapy. The results of the Cape Town five-year prospective evaluation of sclerotherapy with the rigid Negus oesophagoscope using general anaesthesia are presented. We conclude that the combined use of balloon tube tamponade and sclerotherapy has markedly simplified the management of patients with variceal bleeding at our institution. The preliminary results of the 2-year analysis of our ongoing prospective randomised controlled clinical trial comparing the above technique with a new combined paravariceal and intravariceal sclerotherapy technique using a fibreoptic endoscope without anaesthesia are presented. We conclude that both techniques successfully control acute variceal bleeding in the majority of poor-risk patients, but that the rigid scope has some advantages, particularly in those few patients who rebleed at the time of injection. We currently recommend a standard portacaval shunt or a devascularisation and transection procedure for the rare failures of sclerotherapy. Controversial areas of sclerotherapy are reviewed, and a new treatment policy for acute variceal bleeding is proposed on the basis of our experience and a review of the literature.