AbstractThis report emphasizes the importance of emergency endoscopy in the diagnosis of suspected variceal hemorrhage and reviews the role of sclerotherapy at the time of the initial diagnostic endoscopy. With actively bleeding varices, initial control with vasopressin and/or balloon tube tamponade is preferred. Sclerotherapy has been successfully performed by injecting sclerosants intravariceally, paravariceally, or by a combined technique. The best sclerosant to use and the ideal timing of emergency sclerotherapy is as yet unresolved. Successful results have been achieved in Cape Town with intravariceal injections using the rigid endoscope under general anesthesia and recently with a combined technique using a flexible endoscope without an anesthetic. The rare failures of sclerotherapy should be identified early and treated surgically. Injection sclerotherapy is currently the best management for patients who present with proven continued active variceal bleeding. More extensive procedures are unjustified in patients in whom a simple measure such as sclerotherapy is effective in controlling acute variceal bleeding.