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The use of intravenous terlipressin in non-variceal upper GI bleeds
  1. Gabby May, Senior Clinical Fellow in Emergency Medicine,
  2. Dafalla Musa, Senior Clinical Fellow in Emergency Medicine
  1. Manchester Royal Infirmary

    Abstract

    A short cut review was carried out to establish whether terlipressin should be used in upper GI bleeding when variceal bleeding is not suspected as the cause. 556 papers were found, of which none answered the three part question. The clinical bottom line is that there is no evidence for the use of intavenous terlipressin in patients presenting with acute, severe upper GI bleeds unless they have endoscopic evidence of varices or a high clinical index of suspicion is met.

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    Report by Gabby May, Senior Clinical Fellow in Emergency MedicineChecked by Dafalla Musa, Senior Clinical Fellow in Emergency MedicineManchester Royal Infirmary

    Three part question

    [In patients with acute, severe non variceal upper GI bleeding] is [the use of iv terlipressin] indicated to [improve survival, control bleeding and prevent rebleeding]?

    Clinical scenario

    A 65 year old man presents to the emergency department with a large, fresh upper GI bleed. He has a history of NSAID use and complains of increasing indigestion over the last few months. You think some of this may be due to the fact he drinks 35 units of alcohol a week. On examination, he has no stigmata of chronic liver disease and is unwell with a BP of 80 systolic and tachycardia of 140.

    In view of his history and lack of positive examination findings you feel that the most likely diagnosis is a bleeding peptic ulcer.

    You wonder if there is any evidence to support the use of intravenous terlipressin in non variceal upper GI bleeds.

    Search strategy

    MEDLINE (OVID interface) 1960–April 2006 and COCHRANE (via NELH) 2006 Issue 1. Medline: {upper gi bleed.mp. OR exp Gastrointestinal Hemorrhage/or exp Hematemesis/OR haematemesis.mp. OR hematemesis.mp OR gastrointestinal adj5 haemorrhage.af. OR gastrointestinal adj5 hemorrhage.af. OR gi adj5 bleed.af. OR peptic ulcer disease.mp. OR exp peptic ulcer/OR gastric ulcer.af. OR duodenal ulcer.af.} AND {terlipressin.mp.OR vasopressin.mp. OR exp vasopressin/OR antidiuretic hormone.mp. OR adh.mp. } Limit to human and English language. Cochrane: “terlipressin and bleeding”.

    Search outcome

    Altogether 556 papers were found, of which none were relevant. Cochrane returned 63 citations, of which none were relevant.

    Comment(s)

    Intravenous terlipressin is used in variceal bleeds for its effect on the splanchnic circulation causing a lowering of portal pressure, and slowing or stopping bleeding. However, in ulcerative bleeding the vessel is commonly arterial rather than from an abnormally dilated vein.

    The effects of terlipressin are generalised, and it is associated with a number of important side effects. In particular it causes generalised arteriolar and venous constriction, which may lead to myocardial ischaemia or infarction, or peripheral vascular ischaemia. Clearly, none of these are desirable in a hypovolaemic shocked patient.

    The dilemma in the emergency department arises when a patient presents in whom variceal bleeding is possible, but much less likely than a ulcerative bleed. A current database search has failed to identify evidence for the use of iv terlipressin in non variceal bleeds and we conclude that in the abscence of known varices it’s use should be restricted.

    CLINICAL BOTTOM LINE

    There is no evidence for the use of intravenous terlipressin in patients presenting with acute, severe upper GI bleeds unless they have endoscopic evidence of varices or a high clinical index of suspicion is met.