A 58-year-old man with a 15-year history of alcohol use disorder presents to the emergency department with haematemesis and melaena. On examination, he is tachycardic (HR 110/min), hypotensive (BP 88/54 mmHg), and has clinical signs of chronic liver disease including spider angiomas, palmar erythema, and ascites. Upper GI endoscopy reveals large oesophageal varices with active bleeding. After initial resuscitation with 2 units of packed RBCs and fresh frozen plasma, what is the most appropriate immediate pharmacological intervention?

Explanation

## Variceal Bleeding Management **Key Point:** Variceal haemorrhage is a medical emergency requiring simultaneous vasoactive drug therapy, endoscopic therapy, and supportive measures. Terlipressin is the vasoactive agent of choice in variceal bleeding. ### Pharmacological Approach to Variceal Bleeding | Agent | Mechanism | Timing | Efficacy | |-------|-----------|--------|----------| | **Terlipressin** | Selective V1 agonist; reduces portal pressure | Immediate, before endoscopy | 60–80% control; reduces mortality | | **Octreotide** | Somatostatin analogue; splanchnic vasodilation | Alternative if terlipressin unavailable | 50–60% control; no mortality benefit | | **Propranolol** | Non-selective β-blocker | Primary/secondary prophylaxis only | Not for acute bleeding | | **PPI (omeprazole)** | Acid suppression | Non-variceal bleeding | Ineffective for varices | ### Clinical Approach to This Case 1. **Immediate recognition:** Active variceal bleeding confirmed on endoscopy in a cirrhotic patient with haemodynamic instability. 2. **Terlipressin indication:** Must be given immediately (even before endoscopy if diagnosis is suspected clinically) to reduce portal pressure and control bleeding. 3. **Dosing:** 2 mg IV stat, then 1 mg IV every 4–6 hours for up to 48 hours or until bleeding is controlled. 4. **Concurrent measures:** - Endoscopic variceal ligation (EVL) or sclerotherapy - Antibiotic prophylaxis (ceftriaxone or norfloxacin) to reduce bacterial peritonitis risk - Restrictive transfusion strategy (target Hb 7–9 g/dL) **High-Yield:** Terlipressin is superior to octreotide in reducing mortality in variceal bleeding and should be the first-line vasoactive drug in India and most international guidelines [cite:Harrison 21e Ch 295]. **Clinical Pearl:** The combination of vasoactive drugs + endoscopic therapy achieves haemostasis in >80% of cases. Failure to control bleeding after 2 endoscopic attempts requires consideration of transjugular intrahepatic portosystemic shunt (TIPS) or balloon tamponade as a bridge. **Mnemonic:** **STOP Varices** — **S**omatostatin/terlipressin, **T**ransfusion (restrictive), **O**ctreotide (if terlipressin unavailable), **P**roton pump inhibitors (non-variceal only). ### Why Terlipressin Over Octreotide? - Terlipressin has a longer half-life (60 min) and more potent V1 receptor agonism - Octreotide is a reasonable alternative but has no proven mortality benefit - In resource-limited settings, octreotide may be used if terlipressin is unavailable ```mermaid flowchart TD A[Haematemesis + Haemodynamic instability]:::outcome --> B{Clinical suspicion of varices?}:::decision B -->|Yes| C[Immediate terlipressin 2 mg IV]:::action B -->|No| D[PPI + fluid resuscitation]:::action C --> E[Urgent endoscopy]:::action E --> F{Varices confirmed?}:::decision F -->|Yes| G[EVL/sclerotherapy + continue terlipressin]:::action F -->|No| H[Manage non-variceal source]:::action G --> I[Antibiotic prophylaxis]:::action I --> J[Restrictive transfusion]:::action J --> K[Haemostasis achieved]:::outcome ```