Nov 2003

142. Ans. is (a) i.e. Intravenous Vasopressin [Ref: Sabiston 18/e p1211 (17/e p1252;16/e p824)
Maingot's 10/e, p295]
Though vasopressin can be used in acute variceal bleeding, it should possibly be avoided because of
its side-effects.
Management of acute G.I. bleeding After the initial general management of the patient, the further
management depends upon the cause of the bleeding.
From the option given in the question it is clear that the examiners have enquired about the
management of variceal bleeding.
Management of acute variceal bleeding



Pharmacotherapy in variceal bleeding consists of :
(a) Continuous intravenous infusion of somatostatin analogue octreotide
(b) Though -blocker have no role in the management of acute upper g.i. bleeding, they are used in the
secondary prevention of recurrent variceal bleed. They are the mainstay drugs for prophylaxix.
Prophylatic treatment with proparanolol or nadolol in pts. with large varices appear to decrease the
incidence of bleeding and survival is prolonged.
Vasopressin, though is the most potent vasoconstrictor to control variceal bleeding in the acute
setting, it is best avoided because of its ischemic side-effects. See the below given quotes:
Harrison writes- The medical management of acute variceal hemorrhage includes the use of vasoconstricting
agents, usually somatostatin or Octreotide. Vasopressin was used in the past but is no longer commonly used.
Sabiston In patients with cirrhosis, pharmacologic therapy to reduce portal hypertension is considered even
while preparing for emergent EGD. Vasopressin produces splanchnic vasoconstriction and has been shown to
significantly reduce bleeding when compared with placebo. Unfortunately, this agent results in significant cardiac
vasoconstriction, with resulting myocardial ischemia. Although vasopressin has been combined with nitroglycerin
in clinical practice, somatostatin or its synthetic analogue, octreotide, is now the vasoactive agent of choice.
Maingots Pharmacologic therapy for acute variceal bleeding has a longer history. Vasopressin was the first
drug used and has been largely replaced by somatostatin or one of its analogs. Both of these drugs effectively
reduce portal pressure in the patient with acute variceal bleeding. Vasopressin has significant side effects with
systemic vasoconstriction, and although these can be minimized with a concomitant infusion of nitroglycerin,
clinical practice has moved to the use of octreotide. In Europe, Terlipressin is available, has fewer side effects than
vasopressin, and is widely used for acute variceal bleeding.
Varieceal bleeding suspected based on history
ABCs and resuscitation
Start octreotide infusion
Varieceal bleeding confirmed on EGD
Endoscopic band ligation (or sclerotherapy)
Bleeding stopped?
Balloon tamponade
Consider TIPS of surgical shunt
if TIPS fails or not available
Octerotide for 3-5 days
Complete 7 days of antibiotics
Repeat endoscopic banding every 10-14
days until eliminated
Yes No
Schwartz writes Pharmacologic therapy for the variceal hemorrhage can be initiated as soon as the diagnosis of
variceal bleeding is made. Vasopressin, administered IV at a dose of 0.2 to 0.8 units/min, is the most potent
vasoconstrictor. However, its use is limited by its large number of side effects, and it should be administered for only
a short period of time at high doses to prevent ischemic complications.