Gastroscholar

Suspected variceal bleed: start a vasoactive drug as soon as you think it, and keep it 2-5 days (Baveno VII, PMID 35120736). In the US that drug is usually octreotide. Terlipressin is a vasopressin analog used for HRS-AKI with albumin, not a somatostatin analog and not the default US AVB drip. Albumin has three evidence-based jobs: SBP, large-volume tap, and HRS-AKI.

Original GastroScholar summary card for vasoactive drugs and albumin in cirrhosis. Not a clinical photograph.
Original GastroScholar summary card. Not a clinical photograph. This page does not invent an infusion-pump still.

Experienced teaching points

Clinical Pearls

  1. Start the vasoactive drug before the endoscope enters, not after the first band.
  2. Octreotide is a somatostatin analog. Terlipressin is a vasopressin analog. The leftover stub lumped them. Do not.
  3. SBP albumin is 1.5 g/kg on day 1 and 1 g/kg on day 3 (Sort 1999, PMID 10438259). That is not the LVP dose.
  4. LVP: 8 g albumin per liter removed when you take more than 5 L. A 1 g/dL serum albumin is not itself an infusion order.
  5. Who needs a shunt: TIPS page. Who already has organ failure: ACLF. Bands: variceal page.

GI Endoscopy · 7 min read

Octreotide for Bleed, Terlipressin for HRS, Albumin Only When the Indication Exists

Octreotide and terlipressin are not the same drug. Albumin is not a way to decorate a low serum albumin.

Clinical Bottom Line

Drug Job
Octreotide (US AVB) Somatostatin analog. Start as soon as variceal bleed is suspected. Continue 2-5 days. Pair with endoscopic therapy and antibiotics (Baveno VII, PMID 35120736).
Terlipressin Vasopressin analog. HRS-AKI with albumin in selected patients (CONFIRM: more HRS reversal, more respiratory failure). Not the default US variceal drip. Monitor sodium and oxygen.
Albumin for SBP 1.5 g/kg day 1, 1 g/kg day 3. Sort 1999 (PMID 10438259) cut renal failure and death in high-risk SBP.
Albumin for LVP 8 g per liter when more than 5 L come off. Prevents post-paracentesis circulatory dysfunction.
NSBB Primary and secondary prophylaxis in the clinic, after the bleed is over. Not the acute drip.

Why did the stub get the drugs wrong?

It called terlipressin a somatostatin analog and implied albumin is a cytokine sponge you give to every crashing cirrhotic. Terlipressin constricts splanchnic arterioles through vasopressin receptors. Octreotide works through somatostatin receptors. You can use either class for AVB where both are licensed. In US practice the acute bleed drip is octreotide. Terlipressin entered US practice for HRS-AKI, with a respiratory-failure cost in CONFIRM (Wong, NEJM 2021). Do not start it in a volume-overloaded, hypoxic patient.

Albumin is a drug with indications, not a nutritional supplement. SBP, large-volume paracentesis, and combination therapy for HRS-AKI. A low serum albumin on the morning labs is not one of those indications.

How this fits the bleed bundle

Suspect AVB: vasoactive drug, antibiotics, airway caution, endoscopy within 12 hours, then the TIPS question. Banding is the variceal page. The shunt decision is TIPS. If extra-hepatic organs have already failed, read ACLF before you assume a standard floor pathway.

Selected references

  1. de Franchis R, et al. Baveno VII - Renewing consensus in portal hypertension. J Hepatol. 2022;76:959-974.
  2. Sort P, et al. Effect of intravenous albumin on renal impairment and mortality in cirrhosis with spontaneous bacterial peritonitis. N Engl J Med. 1999;341:403-409.
  3. Wong F, et al. Terlipressin plus albumin for type 1 hepatorenal syndrome. N Engl J Med. 2021;384:818-828. CONFIRM.

Last reviewed September 20, 2026. Written for clinicians writing the drip and the albumin order while endoscopy and IR are being called.

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