A 52-year-old man with alcoholic cirrhosis and portal hypertension presents with haematemesis. Upper endoscopy confirms oesophageal varices. Which drug is the first-line pharmacological agent for acute variceal bleeding?

Question

Accepted Answer

D. Terlipressin. ## First-Line Management of Acute Oesophageal Variceal Bleeding

**Key Point:** Terlipressin is the vasoactive drug of choice for acute variceal haemorrhage in cirrhotic patients with portal hypertension.

### Mechanism of Action
- Terlipressin is a selective V1-receptor agonist (vasopressin analogue)
- Causes splanchnic vasoconstriction → reduces portal pressure and variceal bleeding
- Administered as 2 mg IV bolus, then 1 mg IV every 4–6 hours for up to 5 days

### Why Terlipressin is Superior

| Feature | Terlipressin | Vasopressin | Somatostatin |
|---------|--------------|-------------|---------------|
| **Selectivity** | V1-selective | Non-selective (V1 + V2) | Somatostatin analogue |
| **Systemic effects** | Minimal | Significant (coronary vasoconstriction) | Minimal |
| **Mortality benefit** | Yes (proven) | Equivocal | Equivocal |
| **First-line status** | Yes | No (obsolete) | Alternative |

**High-Yield:** Terlipressin + endoscopic variceal ligation (EVL) is the gold standard combination for acute variceal bleeding. Terlipressin should be started immediately (even before endoscopy) and continued for 2–5 days.

### Clinical Pearl
- Terlipressin has superior survival benefit compared to vasopressin (fewer systemic side effects, more selective splanchnic action)
- Contraindicated in coronary artery disease (risk of myocardial infarction)
- Response rate: 80% control of bleeding

### Supportive Measures
- Endoscopic variceal ligation (EVL) — definitive haemostasis
- Blood transfusion (target Hb 7–9 g/dL, avoid over-transfusion)
- Prophylactic antibiotics (ceftriaxone or norfloxacin)
- Correction of coagulopathy if INR > 1.5 or platelet count < 50,000/μL

Answer

A. Propranolol

Answer

B. Spironolactone

Answer

C. Omeprazole

A 52-year-old man with alcoholic cirrhosis and portal hypertension presents with haematemesis. Upper endoscopy confirms oesophageal varices. Which drug is the first-line pharmacological agent for acute variceal bleeding?

Explanation

First-Line Management of Acute Oesophageal Variceal Bleeding

Mechanism of Action

Why Terlipressin is Superior

Clinical Pearl

Supportive Measures

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Feature	Terlipressin	Vasopressin	Somatostatin
Selectivity	V1-selective	Non-selective (V1 + V2)	Somatostatin analogue
Systemic effects	Minimal	Significant (coronary vasoconstriction)	Minimal
Mortality benefit	Yes (proven)	Equivocal	Equivocal
First-line status	Yes	No (obsolete)	Alternative