Can Terlipressin be given in a patient with upper gastrointestinal (GI) bleeding?

Can Terlipressin Be Given in Upper GI Bleeding?

Yes, terlipressin should be given in upper GI bleeding, but ONLY when the bleeding is from esophageal or gastric varices secondary to portal hypertension in cirrhotic patients—it has no role in non-variceal upper GI bleeding. 1, 2

Critical Indication: Variceal Bleeding Only

• Terlipressin is indicated exclusively for bleeding esophageal or gastric varices caused by portal hypertension in patients with cirrhosis 1, 2
• The drug works by causing splanchnic vasoconstriction, which reduces portal venous inflow and lowers portal pressure 1, 2
• Terlipressin has absolutely no role in non-variceal causes of upper GI bleeding (peptic ulcers, Mallory-Weiss tears, gastritis, malignancy) 2

When to Initiate Terlipressin

• Start terlipressin immediately when variceal bleeding is suspected clinically in any cirrhotic patient with upper GI bleeding, even before endoscopic confirmation 1, 3
• Do not wait for diagnostic endoscopy—early initiation improves outcomes 1, 3
• Variceal bleeding should be suspected in any patient with known cirrhosis presenting with hematemesis, melena, or hematochezia 1

Dosing Protocol

• Initial phase: 2 mg IV bolus every 4 hours for the first 48 hours until bleeding is controlled 1, 2, 3
• Maintenance phase: Reduce to 1 mg IV every 4 hours after initial control 1, 2, 3
• Total duration: 2-5 days, with recent evidence suggesting 2 days may be sufficient in selected low-risk patients (Child-Pugh A or B without active bleeding at endoscopy) 1, 4

Mandatory Combination Therapy—Never Monotherapy

Terlipressin should never be used alone. The standard approach requires three simultaneous components: 1, 2, 3

1. Vasoactive therapy (terlipressin) started immediately
2. Endoscopic band ligation performed within 12 hours of presentation
3. Prophylactic antibiotics (ceftriaxone 1g IV daily for up to 7 days)

• Combination therapy achieves 77% five-day hemostasis versus only 58% with endoscopy alone 1, 2
• This triple approach reduces mortality, bacterial infections, and rebleeding 1

Proven Mortality Benefit

• Terlipressin is the only vasoactive drug proven to reduce bleeding-related mortality by 34% (relative risk 0.66,95% CI 0.49-0.88) 2, 3
• This mortality benefit distinguishes terlipressin from octreotide and somatostatin, which have comparable hemostasis rates but lack consistent mortality reduction 1, 2
• Initial bleeding control rates reach 85-90% when combined with endoscopy 1

Gastric Varices: Important Nuance

• While the beneficial effects of vasoactive agents like terlipressin have not been fully proven specifically for gastric variceal bleeding, their use can be recommended given their ability to decrease portal hypertension 5
• The same dosing regimen applies for both esophageal and gastric varices 5, 1
• Gastric fundic varices (GOV2 and IGV1) may require additional interventions like BRTO or PARTO if bleeding is massive or recurrent 5

Absolute Contraindications

Do not give terlipressin if any of the following are present: 1, 2, 3

• Active coronary, peripheral, or mesenteric ischemia
• Hypoxia or worsening respiratory symptoms
• Oxygen saturation <90%
• Pregnancy

Relative Contraindications and Precautions

• Cardiac conditions or coronary artery disease (use with extreme caution) 3
• Progressive hypotension with systolic BP <90 mmHg 3
• Common adverse effects include abdominal pain, nausea, respiratory failure, diarrhea, and dyspnea 1
• Terlipressin increases adverse events 2.39 times compared to octreotide 1

Rescue Therapy for Treatment Failure

• If bleeding persists despite terlipressin and endoscopic therapy, proceed to early transjugular intrahepatic portosystemic shunt (TIPS) placement 2, 3
• High-risk patients (Child-Pugh class C or active bleeding during endoscopy with Child-Pugh B) should be considered for early TIPS 1, 3

Supportive Management Alongside Terlipressin

• Use a restrictive transfusion strategy with hemoglobin threshold of 7 g/dL and target of 7-9 g/dL 5, 3
• Temporarily suspend beta-blockers in hypotensive patients 1
• Volume resuscitation with crystalloids 3

Common Pitfall to Avoid

The most critical error is using terlipressin for non-variceal upper GI bleeding. Always confirm or strongly suspect variceal etiology before initiating therapy. In cirrhotic patients with upper GI bleeding, the high pretest probability of varices justifies empiric treatment while awaiting endoscopy. 1, 2