From the Guidelines
Tranexamic acid (TXA) should not be used to stop gastrointestinal (GI) bleeding, particularly in patients with cirrhosis and active variceal bleeding, due to the lack of beneficial effect and increased risk of thromboembolic events. According to the most recent and highest quality study 1, TXA did not show a beneficial effect in stopping GI bleeding, and its use was associated with an increased risk of venous thromboembolic events. The study found that TXA did not reduce mortality or re-bleeding rates in patients with acute upper gastrointestinal bleeding, including those with suspected variceal bleeding and liver disease comorbidity.
The mechanism of action of TXA involves inhibiting the breakdown of blood clots, which can reduce bleeding in some cases. However, in the context of variceal bleeding, the limited role of haemostasis and the frequent occurrence of a hypofibrinolytic state in critically ill patients with cirrhosis may explain why TXA is ineffective.
Key points to consider when managing GI bleeding include:
- The use of vasoactive therapy, antibiotics, and endoscopic treatment as standard therapy for variceal bleeding
- The potential risks of thromboembolic events associated with TXA use, particularly in patients with comorbid liver disease or suspected variceal bleeding
- The importance of careful patient selection and comprehensive approach to managing bleeding, particularly in cases where standard treatments have failed or are unavailable.
In contrast to the potential benefits of TXA in upper GI bleeding, as suggested by older studies 1, the most recent evidence 1 suggests that TXA should not be used in patients with cirrhosis and active variceal bleeding.
From the Research
Efficacy of Tranexamic Acid in GI Bleeding
- Tranexamic acid (TXA) has been studied as a potential treatment for gastrointestinal (GI) bleeding, with mixed results 2, 3, 4, 5, 6.
- A 2021 systematic review and meta-analysis found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper GI bleeding 2.
- Another study published in 2022 found that extended-use high-dose IV TXA did not reduce mortality or bleeding outcomes, but low-dose IV/enteral TXA may be effective in reducing hemorrhage 3.
- A 2024 meta-analysis found that TXA with acid suppression significantly reduced the risk of rebleeding, units of blood transfused, and the need for salvage therapy in patients with upper GI bleeding 4.
- However, a 2020 systematic review and meta-analysis found that TXA did not improve outcomes in upper GI bleeding and may increase the risk of venous thromboembolic events 5.
- A 2025 comprehensive systematic review and meta-analysis found that TXA significantly reduced rebleeding rates, particularly in upper GI bleeding, and was associated with a mortality reduction when administered through both oral and intravenous routes 6.
Safety and Adverse Events
- The use of TXA in GI bleeding has been associated with an increased risk of thromboembolic events, including deep venous thrombosis and pulmonary embolism 3, 5.
- However, a 2025 meta-analysis found that there was no definitive evidence that TXA use is associated with thromboembolic events 6.
- The safety and efficacy of TXA in lower GI bleeding are less clear, with one study finding that TXA was linked to a significant increase in mortality in patients with lower GI bleeding 6.
Clinical Implications
- The available evidence suggests that TXA may be a useful adjunctive treatment for upper GI bleeding, particularly when combined with acid suppression 2, 4, 6.
- However, the use of TXA in GI bleeding should be approached with caution, taking into account the potential risks and benefits, as well as individual patient factors 3, 5, 6.