Management of Variceal Bleeding

Treatment Recommendations

The recommended dose of terlipressin for variceal bleeding is 2 mg intravenously every 4 hours for the first 48 hours, followed by 1 mg intravenously every 4 hours for an additional 3-5 days, as recommended by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver 1, 2
Terlipressin should be administered as soon as variceal bleeding is suspected, even before endoscopic confirmation, and alongside prophylactic antibiotics, as recommended by the American Association for the Study of Liver Diseases 1, 3, 4
Combination therapy with endoscopic treatment (band ligation) is more effective than either option alone, as recommended by the American Association for the Study of Liver Diseases 1
The standard duration of treatment is 5 days, but a shorter course of 24-72 hours may be considered in selected patients with Child-Pugh A or B cirrhosis and no active bleeding during endoscopy, with a relative risk of bleeding-related mortality of 0.66 (95% CI, 0.49-0.88), as reported by the American Gastroenterological Association and the European Association for the Study of the Liver 5, 6, 4

Terlipressin is contraindicated in patients with hypoxemia (SpO₂ <90%), worsening respiratory symptoms, or ongoing coronary, peripheral, or mesenteric ischemia, as recommended by the American Association for the Study of Liver Diseases, the American Gastroenterological Association, and the Praxis Medical Insights guidelines 1, 5, 7
Caution should be exercised in patients with acute-on-chronic liver failure (ACLF) grade 3, as suggested by the American Association for the Study of Liver Diseases and the American Gastroenterological Association 1, 5

Terlipressin has similar efficacy to somatostatin and octreotide for controlling acute variceal bleeding, with a strength of evidence based on multiple studies, as recommended by the American Association for the Study of Liver Diseases and the American College of Gastroenterology 1, 6, 4
The administration of terlipressin as a continuous infusion may be more effective and safer than traditional intravenous boluses, with a better response in reducing portal pressure and a lower rate of adverse effects, based on recent evidence, as supported by the American Association for the Study of Liver Diseases 4
Adverse effects of terlipressin include hyponatremia, myocardial ischemia, abdominal pain, diarrhea, and hypoxemia, with a recommendation for close monitoring by the European Association for the Study of the Liver, and occur in approximately 12% of patients treated with terlipressin 6, 8
Predictors of response in hepatorenal syndrome (HRS) include serum bilirubin <10 mg/dL before treatment and an increase in mean arterial pressure of >5 mmHg at day 3, as reported by the European Association for the Study of the Liver 8
Treatment with terlipressin is effective in 40-50% of patients with HRS, according to the European Association for the Study of the Liver 8

Patients on terlipressin should be monitored for adverse effects, including oxygen saturation, serum sodium levels, signs of cardiac ischemia, and renal function, as recommended by the American Gastroenterological Association and the European Association for the Study of the Liver 5, 8
Continuous pulse oximetry is recommended to monitor for hypoxia, and treatment should be discontinued if SpO₂ <90%, as suggested by the American Gastroenterological Association 5