What should be given to a complicated cirrhotic patient with portal hypertension and upper GI bleeding due to varices after resuscitation?

Management of Acute Variceal Bleeding in Cirrhotic Patients with Portal Hypertension

Terlipressin should be administered after resuscitation in a cirrhotic patient with portal hypertension and upper GI bleeding due to varices. 1

Initial Management Algorithm

1. Resuscitation Phase

   • Restore hemodynamic stability with crystalloids
   • Restrictive transfusion strategy (hemoglobin threshold of 7 g/dL, target 7-9 g/dL) 1
   • Protect airway if needed (especially with encephalopathy)
   • Place at least two large-bore IV catheters

2. Immediate Pharmacological Therapy

   • Vasoactive drug therapy should be initiated as soon as variceal bleeding is suspected 1
   • Terlipressin is the preferred agent because:
     • It is the only drug with proven efficacy in improving survival 2
     • Recommended dose: 2 mg/4 hours during first 48 hours, then 1 mg/4 hours 1
     • Has twice the selectivity for vasopressin V1 receptors versus V2 receptors 3
     • Reduces portal hypertension and increases mean arterial pressure 3

3. Antibiotic Prophylaxis

   • Administer ceftriaxone or norfloxacin 1
   • Continue for up to 7 days 1

4. Endoscopic Management

   • Perform early diagnostic endoscopy (<12 hours) 1
   • Endoscopic variceal band ligation is the preferred method 1
   • If banding is difficult due to active bleeding, sclerotherapy can be performed 1

Comparative Efficacy of Vasoactive Agents

While all three options (terlipressin, somatostatin, and octreotide) are accepted drugs with proven efficacy in controlling acute variceal bleeding 1, terlipressin has distinct advantages:

• Terlipressin (Option B): The only vasoactive agent shown to improve survival in variceal bleeding 2. It has a longer half-life (0.9 hours) compared to other agents 3, allowing for bolus administration rather than continuous infusion.

• Somatostatin (Option A): Requires continuous infusion of 250 μg/h with an initial bolus of 250 μg 1. While effective in controlling bleeding, it has not been shown to reduce mortality 2.

• Octreotide (Option C): Requires continuous infusion of 50 μg/h with an initial bolus of 50 μg 1. Like somatostatin, it is effective for bleeding control but has not demonstrated mortality benefits 2.

Duration of Vasoactive Therapy

• Continue vasoactive drug therapy for 3-5 days after diagnosis is confirmed 1, 2
• This duration is critical to prevent early rebleeding

Special Considerations

• For patients with high risk of treatment failure (Child B with active bleeding or Child C <14 points), consider early TIPS within 72 hours 2
• If bleeding is not controlled with pharmacological and endoscopic therapy, rescue TIPS using covered stents is the best alternative 1, 2
• Balloon tamponade may be used as a temporary bridge to TIPS in refractory bleeding 2

Common Pitfalls to Avoid

1. Excessive volume resuscitation: Can increase portal pressure and precipitate rebleeding 1
2. Delayed initiation of vasoactive drugs: Should start as soon as variceal bleeding is suspected, even before endoscopic confirmation 1
3. Inadequate duration of therapy: Premature discontinuation of vasoactive drugs increases risk of rebleeding 2
4. Overlooking antibiotic prophylaxis: Critical to prevent bacterial infections that increase rebleeding risk and mortality 1

In conclusion, based on the most recent and highest quality evidence, terlipressin (Option B) is the correct answer for management after resuscitation in a cirrhotic patient with portal hypertension and upper GI bleeding due to varices.