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Acute bleeding from esophageal varices is a medical emergency. It requires a structured therapeutic strategy which is adapted to the local resources. The primary goal is to stop bleeding, preferably by endoscopic sclerotherapy or ligation. In situations where endoscopic intervention is not possible as a first-line treatment, therapy with balloon tamponade or vasoactive drugs (terlipressin or octreotide) are options to be followed as soon as possible by sclerotherapy or ligation. After successful hemostasis, the next goal is to prevent rebleeding. This is achieved primarily by eradicating sclerotherapy or ligation. In special situations, long-term therapy with a non-cardio-selective beta receptor blocker is an alternative. The combined approach of sclerotherapy or ligation plus beta receptor blocker has no significant advantage. Primary prophylaxis of bleeding from esophageal varices by long-term beta receptor blocker therapy is advised in patients with medium-sized or large varices. Apart from strategies aimed at the therapy or prophylaxis of bleeding from esophageal varices, measures to prevent and treat chronic liver diseases should be implemented in order to reduce the development of liver cirrhosis as the leading cause of esophageal varices.