Pharmacological treatment of bleeding oesophageal varices
Date First Published:
November 23, 2000
Last Updated:
December 20, 2002
Report by:
Russell Boyd, Consultant in Emergency Medicine (Manchester Royal Infirmary)
Search checked by:
John Butler, Manchester Royal Infirmary
Three-Part Question:
In [adults with known varices] is [terlipressin] effective at [reducing acute bleeding]?
Clinical Scenario:
A 55 year old male presents with massive haematemesis. He has known oesophageal varices. He is tachycardic, peripherally shut down and continues to actively vomit fresh blood. You wonder if pharmacolgical treatment with terlipressin will be effective in reducing the bleeding.
Search Strategy:
Medline 1966 to 11/02 using OVID interface.
Search Details:
[{exp Gastro-intestinal haemorrhage-all sub-headings] or [exp esophageal varices-all sub-headings}] and [exp lypressin or exp Vasopressin] and [exp Clinical trials-all sub-headings].
Outcome:
23 papers were identified of which 3 were relevant to the above clinical question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Terlipressin in bleeding esophageal varices: a placebo-controlled, double-blind study. Walker S, Stiehl A, Raedsch R, et al. 1986, Germany | 34 patients with 50 endoscopically proven oesophageal variceal bleeds | Double blinded randomised placebo controlled trial | Hospital mortality | 3/25 (12%) in terlipressin group and 8/25 (32%) in control group | The use of balloon tamponade was added in a "non-controlled" fashion |
| Cessation of bleeding for a continuous 24 hour period within 36 hours of randomisation (p<0.05) | 25/25 (100%) bleeding episodes were terminated in the terlipressin group with 20/25 (80%) terminated in the placebo group | ||||
| Placebo-controlled trial of terlipressin (glypressin) in the management of acute variceal bleeding. Freeman JG, Cobden I and Record CO. 1989, UK | 29 patients with active variceal bleed proven on endoscopy | Double blind placebo controlled clinical trial | Cessation of active blood loss on clinical grounds | 9/15 (60%) of terlipressin treated patients ceased bleeding compared with 6/16 (37%) of placebo treated patients ceased bleeding. Statistical significance not reached | Small numbers ensuring possible type 2 error |
| Terlipressin (triglycyl-lysine vasopressin) controls acute bleeding oesophageal varices. A double-blind, randomized, placebo-controlled trial. Soderlund C, Magnusson I, Torngren S, et al. 1990, Sweden | 60 patients with endoscopically proven acutely bleeding oesophageal varices | Double blinded randomised placebo controlled trial | Need for balloon tamponade or rescue endoscopy within 24 hours of randomisation | No need for active intervention (balloon tamponade or rescue endoscopy) in 28/31 (90%) of the terlipressin group and in 17/29 (59%) of the placebo group (p<0.01) | The criteria for initiating balloon tamponade or endoscopy were not explicit |
Author Commentary:
Small but reasonable quality studies indicate that terlipressin is significantly better than placebo in reducing blood loss from actively bleeding oesophageal varices.
Bottom Line:
Use of terlipressin as a pharmacological aid to reducing active oesophageal variceal bleeding appears indicated and effective
References:
- Walker S, Stiehl A, Raedsch R, et al.. Terlipressin in bleeding esophageal varices: a placebo-controlled, double-blind study.
- Freeman JG, Cobden I and Record CO.. Placebo-controlled trial of terlipressin (glypressin) in the management of acute variceal bleeding.
- Soderlund C, Magnusson I, Torngren S, et al.. Terlipressin (triglycyl-lysine vasopressin) controls acute bleeding oesophageal varices. A double-blind, randomized, placebo-controlled trial.