Acute variceal bleeding is a life-threatening complication in patients with portal hypertension. Although overall survival may be improving, mortality is still closely related to failure to control hemorrhage or early re-bleeding. Factors that influence this failure include severity of liver disease and active bleeding during endoscopy. In addition increased portal pressure has been proposed as a prognostic factor of early re-bleeding. There is also a strong association between variceal hemorrhage and bacterial infection. Recent meta-analyses confirmed that antibiotic prophylaxis significantly increases the short-term survival rate. Effective resuscitation,protection of the airway, particularly with severe bleeding and disturbed conscious level, especially during endoscopy are initial priorities. The following treatment strategies have been compared: a)Vasoactive drugs (±tamponade) vs Vasoactive drugs (±tamponade)+ sclerotherapy, b)vasoactive drugs vs sclerotherapy, c)vasoactive drugs+ endoscopy vs endoscopy, d)sclerotherapy vs ligation and e)Recombinant factor VII +endoscopy vs placebo+endoscopy. According to Baveno IV Consensus endoscopic treatments are best used in association with pharmacological therapy, which preferably should be started before endoscopy. Lastly in order to identify the group with poor outcome, new diagnostic/treatment algorithms are needed using known predictive factors. In this group more effective vasoactive regimens, early TIPS, and the use of self-expanding covered oesophageal stent could be considered.