• terlipressin
• vasopressin analogue
• arterial blood volume
• tense ascites
• cirrhosis

• coeliac disease
• oats
• diet

Moreau et al described the use of terlipressin, a vasopressin analogue, in ameliorating the reduction in effective arterial blood volume which can occur after paracentesis for tense ascites in cirrhosis (Gut 2002:50:90–4).

The article states that the first 1 mg intravenous bolus dose of terlipressin was given at the onset of paracentesis. Previous work has shown that infusion of vasopressin in a haemodynamically stable circulation can lead to reduced cardiac performance and coronary blood flow.¹ Moreover, a sustained pressor response can occur in cirrhotic patients, with reduction in heart rate, cardiac output, hepatic blood flow, and pressor effects also on the pulmonary circulation.²

Although the authors state no episodes of arterial hypertension occurred in the terlipressin group and that there were no observed changes between pre- and post-treatment electrocardiograms (ECGs), it is not clear whether invasive continuous arterial pressure monitoring was employed in this study or whether continuous ECG readings were taken. Without this level of observation it is difficult to exclude the occurrence of transient asymptomatic episodes of cardiac ischaemia.

Exclusion of patients with a history of cardiac disease, cardiac failure, renal disease, and diabetes mellitus may render the conclusions of this pilot study, and those of any subsequent randomised controlled trials with the same exclusion criteria, difficult to interpret and apply. One may argue that it is these subgroups of patients with comorbid factors who are most likely to suffer the deleterious consequences of a reduction in effective arterial blood volume of any duration or magnitude.