After initial stabilization with intravenous fluids and blood products, the patient develops another bout of bloody emesis. Urgent upper gastrointestinal endoscopy confirms esophageal varices. Which of the following peptides is most likely to immediately decrease the portal venous pressure in this patient?

Question

After initial stabilization with intravenous fluids and blood products, the patient develops another bout of bloody emesis.  Urgent upper gastrointestinal endoscopy confirms esophageal varices.  Which of the following peptides is most likely to immediately decrease the portal venous pressure in this patient?

Quizplus · Accepted Answer

Prolonged portal hypertension in alcohol-associated liver disease can cause venous engorgement and dilation (ie, varices) at sites of portocaval anastomosis in the esophagus, rectum, umbilicus, and retroperitoneum. Subsequent rupture of esophageal varices can cause rapid blood loss and carries high mortality. Acute management of variceal hemorrhage requires rapid lowering of portal pressure. Somatostatin and octreotide (a long-acting somatostatin analog) inhibit the release of endogenous hormones (eg, glucagon, vasoactive intestinal peptide) that induce splanchnic vasodilation, thereby indirectly reducing portal blood flow. Vasopressin directly causes splanchnic vasoconstriction and also can lower portal flow in acute variceal hemorrhage, but its use is limited by systemic vasoconstriction. (Choices A, B, and D) Glucagon causes splanchnic vasodilation, raising portal pressure and worsening variceal bleeding. Cholecystokinin induces contraction of the gallbladder and expulsion of pancreatic exocrine secretions into the duodenum, whereas the primary function of secretin is to alkalinize the duodenal contents; both of these hormones increase glucagon secretion and would therefore be counterproductive in this setting. (Choice C) Pentagastrin is a synthetic gastrin analog that stimulates secretion of gastric acid. Its primary clinical use is as a diagnostic agent; pentagastrin induces a significant rise in calcitonin secretion in patients with medullary carcinoma of the thyroid and serotonin secretion in patients with carcinoid tumors. Educational objective: Acute management of variceal hemorrhage requires rapid lowering of portal pressure. Somatostatin and octreotide (a long-acting somatostatin analog) inhibit the release of hormones that induce splanchnic vasodilation, indirectly causing splanchnic vasoconstriction and reduced portal blood flow. __________ References: Portal hypertension and variceal hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/19577117) Acute variceal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/22447260)

After Initial Stabilization with Intravenous Fluids and Blood Products, the Patient