A 50-year-old man with Child-Pugh C cirrhosis (alcoholic) presents with sudden large-volume haematemesis. Endoscopy confirms oesophageal variceal bleeding which is controlled with band ligation. The MOST appropriate pharmacological agent to add alongside endoscopic therapy to reduce early re-bleeding and portal pressure is:
- A Propranolol started immediately post-banding
- B Somatostatin or terlipressin started before or within 2 hours of endoscopy ✓
- C Spironolactone 400 mg daily to reduce portal hypertension
- D Tranexamic acid to inhibit fibrinolysis
Correct answer: B. Somatostatin or terlipressin started before or within 2 hours of endoscopy
Explanation
Current Baveno VII (2022) guidelines strongly recommend vasoactive drugs (terlipressin, somatostatin, or octreotide) be initiated as soon as variceal bleeding is suspected — ideally in the ambulance — and continued for 2–5 days after endoscopy. These agents reduce splanchnic blood flow and portal pressure, decrease active bleeding, and improve endoscopic conditions. Non-selective beta-blockers (propranolol, carvedilol) are used for secondary prophylaxis but not during the acute bleed. Spironolactone targets ascites, not variceal bleeding acutely.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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