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 **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