## Acute Variceal Bleeding Management **Key Point:** Terlipressin is the first-line pharmacological agent for acute esophageal variceal bleeding in cirrhosis, used alongside endoscopic therapy (EVL or sclerotherapy). ### Mechanism of Action Terlipressin is a selective vasopressin V1 receptor agonist that causes splanchnic vasoconstriction, reducing portal pressure and variceal bleeding. ### Drug Comparison Table | Drug | Class | Timing | Role | Efficacy | |------|-------|--------|------|----------| | **Terlipressin** | Vasopressin analogue | Acute bleeding | First-line pharmacotherapy | 60–80% control | | Propranolol | Beta-blocker | Prophylaxis | Secondary prophylaxis only | Not for acute bleeding | | Nitrates | Vasodilator | Adjunct | Reduces portal pressure | Modest; used with terlipressin | | Omeprazole | PPI | Supportive | GI protection | No role in variceal bleeding | ### Clinical Protocol 1. **Immediate steps:** IV access, blood products, correction of coagulopathy 2. **Terlipressin dosing:** 2 mg IV bolus, then 1 mg IV every 4–6 hours for up to 48 hours 3. **Concurrent therapy:** Endoscopic variceal ligation (EVL) is the gold standard; terlipressin buys time and reduces rebleeding 4. **Adjuncts:** Antibiotics (ceftriaxone) for SBP prophylaxis; consider octreotide if terlipressin unavailable **High-Yield:** Terlipressin has superior mortality benefit over octreotide in acute variceal bleeding [cite:Harrison 21e Ch 308]. **Clinical Pearl:** Propranolol is reserved for *secondary prophylaxis* (prevention of rebleeding after initial control) and *primary prophylaxis* in high-risk patients; it has no role in acute bleeding management. **Warning:** Do not confuse acute variceal bleeding management (terlipressin + EVL) with chronic prophylaxis (propranolol ± EVL). Many students incorrectly choose propranolol for acute scenarios.
Sign up free to access AI-powered MCQ practice with detailed explanations and adaptive learning.