Biliary pancreatitis secondary to stones from a gall bladder remnant.

Since its introduction in the early 1990s, terlipressin has revolutionized management of liver disease with a role in the treatment of variceal haemorrhage and hepatorenal syndrome. Terlipressin has proven to be safe, with a lower incidence of side-effects compared with vasopressin and other synthetic analogues. Although, terlipressin is selective for the spanchnic circulation, it can exert vasoconstrictor effects on the systemic circulation. Undesirable effects are usually mild and include headache, abdominal pain and bradycardia. More serious complications are uncommon, but cases of ischaemic colitis, myocardial infarction and skin necrosis have been reported. We believe that the skin lesion seen in this patient occurred as a result of terlipressin therapy. There is evidence for a temporal relationship between terlipressin and the observed skin necrosis. The manufacturers of terlipressin (Ferring Pharmaceuticals Ltd, Saint-Prex, Switzerland) have received 10 reports of skin necrosis related to terlipressin use. The majority of cases are related to skin necrosis affecting the extremities, but there are also a small number of cases of foreskin and scrotal necrosis in males. Ischaemic complications as a result of vasoconstrictor medication usually affect peripheral areas such as the digits of the hands and feet. This case suggests extra vigilance is warranted while administering terlipressin. Although ischemic complication with terlipressin is rare, we should be aware of it and detect it early.