BACKGROUND: Acute variceal hemorrhage (AVH) is an important complication of cirrhosis that carries a high mortality rate. Management of AVH requires early initiation of specialized care that may be more readily available at centers that deal with a high volume of AVH. OBJECTIVE: Our purpose was to examine the relationship between the annual hospitalization volume and the in-hospital mortality rate for AVH. DESIGN: Cross-sectional study from a national representative sample. SETTING: A 20% sample of all nonfederal short-term hospitals from 37 states participating in the Nationwide Inpatient Sample 2004. PATIENTS: A total of 28,817 discharges with AVH identified through appropriate International Classification of Diseases, 9th Revision, Clinical Modification codes for bleeding esophageal varices. Hospitals were divided into low-, medium-, and high-volume hospitals if they had 1 to 15, 16 to 35, and 36 or more annual discharges related to AVH. MAIN OUTCOME MEASUREMENT: In-hospital mortality rate. RESULTS: On multivariate analysis, there was no significant difference in the mortality rate either for medium- (odds ratio [OR] 0.84; 95% CI, 0.67-1.05) or high-volume hospitals (OR 1.06; 95% CI, 0.82-1.37). However, patients both at medium- (OR 1.27; 95% CI, 1.02-1.58) and high-volume hospitals (OR 1.40; 95% CI, 1.07-1.84) were more likely to undergo endoscopy for AVH. Endoscopic intervention for control of variceal hemorrhage was significantly more common in medium- (OR 1.20) and high- (OR 1.33) volume hospitals. Patients at medium- (OR 3.10; 95% CI, 2.09-4.60) and high-volume hospitals (OR 4.12; 95% CI, 2.52-6.75) were also more likely to undergo transjugular intrahepatic portosystemic shunt (TIPS). CONCLUSION: Higher hospital volume is associated with greater rates of endoscopy, endoscopic intervention, and higher utilization of TIPS in the management of AVH.