Acute variceal bleeding (AVB) is a life threatening complication occurring in patients with portal hypertension and remains a leading cause of death in patients with cirrhosis. Advances in management, including adequate resuscitation, use of prophylactic antibiotics, and vasoactive drugs, have significantly improved the mortality associated with variceal bleeding, which remains at 11–20% per episode. Early endoscopy is a key management priority in all patients with AVB; esophageal varices are preferentially treated with endoscopic variceal ligation and gastric varices with variceal obturation or injection. Rescue therapies are available for patients with bleeding refractory to early endoscopic management and include balloon tamponade, covered metal stent insertion, and transjugular intrahepatic portosystemic shunt insertion. Ectopic variceal bleeding is an uncommon clinical entity that may originate from any point in the gastrointestinal tract.