## Clinical Scenario Analysis This patient has decompensated cirrhosis with acute variceal haemorrhage (haematemesis in the setting of portal hypertension). Despite initial resuscitation, he remains at high risk for rebleeding and mortality. ## Management Algorithm for Variceal Bleeding ```mermaid flowchart TD A[Variceal bleeding suspected]:::outcome --> B[Resuscitate + Secure airway]:::action B --> C{Haemodynamically stable?}:::decision C -->|Yes| D[Start vasoactive agent + Antibiotics]:::action C -->|No| E[Continue resuscitation]:::action E --> D D --> F[Urgent endoscopy within 12 hours]:::action F --> G[Variceal ligation/sclerotherapy]:::action G --> H[Continue vasoactive agent 2-5 days]:::action ``` ## Key Point: Vasoactive Agents in Variceal Bleeding **Terlipressin** is the vasoactive agent of choice in variceal haemorrhage because: - Splanchnic vasoconstriction reduces portal pressure - More selective than vasopressin (fewer systemic side effects) - Should be started **immediately** upon clinical suspicion, even before endoscopy - Reduces mortality by ~34% when given early [cite:Harrison 21e Ch 297] **Octreotide** is an alternative somatostatin analogue: - Longer half-life than vasopressin - Often used as continuous infusion (50 µg/hr) alongside terlipressin - Less potent than terlipressin but fewer contraindications ## High-Yield: Antibiotic Prophylaxis **Ceftriaxone 1 g daily** (or norfloxacin 400 mg BD) should be started immediately in all variceal bleeding patients: - Reduces bacterial infections (SBP, UTI, pneumonia) by ~50% - Improves survival in cirrhosis - Start **before or with** vasoactive agents, not after stabilisation ## Endoscopy Timing - **Urgent endoscopy within 12 hours** of presentation (not delayed 24 hours) - Allows definitive diagnosis (oesophageal vs. gastric varices) - Permits therapeutic intervention (endoscopic variceal ligation or sclerotherapy) - Variceal ligation is superior to sclerotherapy (lower rebleeding, lower mortality) ## Clinical Pearl In a haemodynamically unstable patient with suspected variceal bleeding, **do not wait for endoscopy confirmation** — start vasoactive agents and antibiotics immediately. The risk of death from ongoing bleeding outweighs the risk of treating a non-variceal source. ## Why This Patient Needs Terlipressin NOW - Child-Pugh C cirrhosis = very high mortality risk - Haemodynamic instability despite transfusion = severe bleeding - Terlipressin + octreotide + endoscopy is the standard of care - Every hour of delay increases mortality
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