Intravenous Medication for Esophageal Variceal Bleeding
Administer octreotide intravenously immediately: 50 mcg IV bolus (can be repeated in the first hour if ongoing bleeding), followed by continuous infusion of 50 mcg/hour for 2-5 days. 1, 2, 3
Primary Vasoactive Agent Selection
Octreotide is the preferred vasoactive agent available in the United States for acute esophageal variceal bleeding. 1, 2 While terlipressin demonstrates superior mortality reduction (34% relative risk reduction), it remains investigational in the U.S. and is not FDA-approved for variceal bleeding. 1, 4, 2
Octreotide Administration Protocol
- Initial bolus: 50 mcg IV (repeat if bleeding continues within first hour) 1, 2
- Continuous infusion: 50 mcg/hour 1, 2
- Duration: 2-5 days (may discontinue after definitive endoscopic hemostasis) 1, 2, 3
- Start immediately: Do not wait for endoscopy—begin upon clinical suspicion of variceal bleeding 1, 2
Alternative Vasoactive Agents (if octreotide unavailable)
- Somatostatin: 250 mcg IV bolus, then 250 mcg/hour infusion 1, 2, 5
- Terlipressin (if available outside U.S.): Continuous infusion 4 mg/24 hours is superior to bolus dosing, providing 85% vs 58% reduction in hepatic venous pressure gradient 4, 2
Role of Proton Pump Inhibitors
PPIs are NOT required when using somatostatin analogs (octreotide) because these agents already inhibit gastric acid secretion. 1 Co-administration of PPIs provides no additional benefit in variceal bleeding management and should not be prioritized over vasoactive therapy. 1
Critical Timing and Combination Therapy
Vasoactive drugs must be started immediately—even before diagnostic endoscopy—as early administration facilitates endoscopy, improves hemostasis rates (77% vs 58%), and reduces 5-day mortality. 1, 2 The combination of vasoactive drugs plus endoscopic therapy is superior to endoscopic treatment alone. 1, 2
Evidence Supporting Early Vasoactive Therapy
Meta-analysis of eight studies demonstrated that combination therapy (vasoactive drugs + endoscopy) achieved 77% 5-day hemostasis compared to 58% with endoscopy alone. 1 Vasoactive agents reduce splanchnic blood flow and portal pressure, providing a clearer endoscopic field and reducing transfusion requirements. 1
Mandatory Adjunctive Therapy
Administer ceftriaxone 1 g IV daily (maximum 7 days) for antibiotic prophylaxis—this reduces mortality, bacterial infections, and rebleeding. 1, 3 Antibiotic prophylaxis demonstrated significant mortality reduction (RR 0.73) and decreased bacterial infections (RR 0.40) in meta-analysis of over 1,200 patients. 1
Common Pitfalls to Avoid
- Do NOT delay vasoactive drugs waiting for endoscopy confirmation—start immediately upon clinical suspicion 1, 2
- Do NOT use non-selective beta-blockers during acute bleeding—these are reserved for secondary prophylaxis after bleeding control 2
- Do NOT add PPIs thinking they enhance variceal bleeding control—octreotide already suppresses acid secretion 1
- Do NOT overtransfuse—maintain restrictive transfusion strategy (hemoglobin 7-9 g/dL) to avoid increasing portal pressure 1, 2, 3
Monitoring During Octreotide Therapy
Monitor for adverse effects including abdominal pain, nausea, and hyperglycemia, though octreotide has a favorable safety profile compared to vasopressin. 1, 5 Continue therapy for 2-5 days as adjuvant to endoscopic intervention. 1, 2, 3