Terlipressin-Associated Metabolic Acidosis: A Case report

Background: Terlipressin, a vasopressin analogue, is widely used in managing complications of portal hypertension, including variceal bleeding and hepatorenal syndrome. While generally well tolerated, rare but serious systemic adverse effects may occur due to its potent vasoconstrictive properties. Case Presentation: We present the case of a 71-year-old male with cirrhosis who developed acute neurological symptoms, restlessness, diarrhea, and high anion gap metabolic acidosis with lactic elevation during terlipressin therapy for suspected gastrointestinal bleeding. The symptoms resolved following discontinuation of terlipressin, suggesting drug-induced systemic hypoperfusion affecting both mesenteric and cerebral circulations. Discussion: This case illustrates how terlipressin’s potent systemic vasoconstrictive effects can unmask or aggravate extra-splanchnic ischemia in vulnerable cirrhotic patients, emphasizing the importance of monitoring for neurological, gastrointestinal, and metabolic changes as early markers of serious toxicity. Conclusion: This case highlights the potential for significant extra-splanchnic adverse effects of terlipressin. Clinicians should remain vigilant for early signs of systemic vasoconstriction, particularly in elderly or comorbid patients, and consider prompt discontinuation when adverse effects are suspected.