## Acute Variceal Hemorrhage Management **Key Point:** Octreotide is the first-line pharmacological agent for acute variceal bleeding in cirrhosis. It reduces portal pressure by causing splanchnic vasoconstriction and is given as an IV bolus followed by continuous infusion. ### Mechanism of Action Octreotide is a somatostatin analogue that: - Causes selective splanchnic vasoconstriction - Reduces portal blood flow and portal pressure - Decreases variceal pressure gradient - Does NOT require hepatic metabolism (safe in liver failure) ### Dosing in Acute Variceal Bleed - **IV bolus:** 50 mcg over 1 minute - **Continuous infusion:** 50 mcg/hour for 2–5 days - Continued during and after endoscopic therapy ### Why Octreotide Over Alternatives | Feature | Octreotide | Propranolol | Omeprazole | Sucralfate | |---------|-----------|------------|-----------|----------| | **Onset** | Immediate (minutes) | Slow (hours–days) | Not applicable | Not applicable | | **Acute bleed role** | First-line | Prophylaxis only | Adjunct (acid suppression) | Adjunct (mucosal protection) | | **Portal pressure reduction** | Yes (splanchnic vasoconstriction) | Yes (but slow) | No | No | | **Hepatic metabolism** | Minimal | Yes (contraindicated in severe liver disease) | Yes | Minimal | **High-Yield:** Octreotide + endoscopic variceal ligation (EVL) is the gold standard for acute variceal hemorrhage. Propranolol is used for *secondary prophylaxis* (prevention of rebleeding), not acute bleeding. **Clinical Pearl:** Octreotide must be started *before* endoscopy and continued for 2–5 days. Early use improves hemostasis and reduces rebleeding rates by ~30%. **Mnemonic:** **OCTREOTIDE = Occludes Splanchnic Circulation, Therapeutic in Emergency** — immediate action in acute bleed.
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