A 58-year-old man with cirrhosis and portal hypertension presents with haematemesis and melena. Endoscopy confirms oesophageal variceal bleeding. After initial resuscitation and blood product transfusion, what is the drug of choice for acute variceal haemorrhage?

Explanation

## Acute Oesophageal Variceal Bleeding: Pharmacological Management **Key Point:** Terlipressin is the vasoconstrictor of choice for acute variceal haemorrhage, used alongside endoscopic therapy. ### Mechanism of Terlipressin Terlipressin is a selective vasopressin V₁ receptor agonist that: 1. Causes splanchnic vasoconstriction → reduces portal pressure 2. Decreases azygos blood flow → reduces variceal pressure gradient 3. Has minimal systemic vasoconstrictive effects compared to vasopressin 4. Can be used safely in patients with cardiac comorbidity (relative advantage over vasopressin) ### Role in Acute Variceal Bleeding Terlipressin is administered **immediately upon diagnosis** (before or during endoscopy) and continued for 2–5 days: - **Dosing:** 2 mg IV bolus, then 1 mg IV every 4–6 hours (or 0.03 mg/kg/4h) - **Efficacy:** Controls bleeding in ~80% of cases when combined with endoscopic therapy - **Evidence:** Superior to vasopressin; reduces rebleeding and mortality [cite:Harrison 21e Ch 297] ### Comparison with Other Agents | Agent | Indication | Timing | Limitation | | --- | --- | --- | --- | | **Terlipressin** | Acute variceal bleed | Immediate, before endoscopy | Cost, systemic effects (angina, MI) | | **Octreotide** | Acute variceal bleed | Immediate, adjunct to endoscopy | Less effective than terlipressin; used if unavailable | | **Propranolol** | Variceal prophylaxis (primary/secondary) | Long-term, chronic | No role in acute bleeding | | **Omeprazole** | Non-variceal UGI bleed | Acute & chronic | No effect on portal pressure | **High-Yield:** Terlipressin + endoscopic variceal ligation/sclerotherapy is the standard of care for acute variceal haemorrhage. Terlipressin is given **before** endoscopy is performed. **Clinical Pearl:** In resource-limited settings where terlipressin is unavailable, octreotide (50 µg bolus, then 50 µg/h infusion) is an acceptable alternative, though less potent. **Warning:** Do not confuse propranolol (a beta-blocker used for **prophylaxis** of variceal bleeding) with terlipressin (used for **acute** bleeding control).