Can tranexamic acid (TXA) stop a lower gastrointestinal (GI) bleed?

From the Guidelines

Tranexamic acid (TXA) is not recommended as a primary treatment to stop a lower GI bleed, but it may be considered for patients with mild GI bleeding due to its low potential for harm, although its effectiveness is limited. The management of lower GI bleeding typically involves identifying and treating the underlying cause through endoscopic intervention, radiological procedures, or surgery when necessary 1. Initial management includes hemodynamic stabilization, blood transfusions if needed, correction of coagulopathies, and prompt diagnostic evaluation with colonoscopy. Some key points to consider when managing lower GI bleeding include:

• Identifying the source of the bleed, which can be challenging due to the location and accessibility of the lower GI tract
• Using procedural hemostatic treatments, such as Argon Plasma Coagulation, only to treat emergent or brisk bleeds, as there is limited evidence to support their systematic use 1
• Considering systemic therapies, such as bevacizumab, for patients with moderate or severe GI bleeding, as they have shown substantial improvements in mean hemoglobin and reduced need for red cell transfusions 1
• Weighing the potential benefits and risks of using TXA, including its low potential for harm, but limited evidence of effectiveness for lower GI bleeding 1.

From the Research

TXA and Lower GI Bleed

• The use of tranexamic acid (TXA) in lower GI bleeding is still unclear, with some studies suggesting it may not be effective in reducing blood loss or improving clinical outcomes 2.
• A randomized placebo-controlled clinical trial found no difference in hemoglobin drop, transfusion rates, or intervention rates for bleeding between patients treated with TXA and those receiving a placebo 2.
• However, another study suggested that TXA may be effective in reducing the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding, but its effects on lower gastrointestinal bleeding warrant further clarification 3.

Management of Lower GI Bleed

• The initial assessment of patients presenting with acute lower gastrointestinal bleeding should include a history of co-morbidities and medications that promote bleeding, hemodynamic parameters, physical examination, and laboratory markers 4.
• Colonoscopy is recommended for patients with major acute lower gastrointestinal bleeding, but the timing of the procedure is not clearly defined 4.
• Computed tomography angiography may be useful in locating the site of bleeding in patients with hemodynamic instability and suspected ongoing bleeding 4.
• The use of haemostatic agents, such as TXA, may provide an additional tool for the management of bleeding endoscopically in difficult situations 5.

Clinical Outcomes

• The clinical outcomes of patients with lower GI bleeding may be improved with appropriate decision-making, including emergency hospitalization, timing of colonoscopy, and medication use 6.
• Early timing of colonoscopy may improve identification of the bleeding source and the rate of endoscopic intervention 6.
• The management of antithrombotic agents, such as aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), after hemostasis should be carefully considered due to the risk of rebleeding and thromboembolic events 4, 6.