From the Guidelines
Tranexamic acid (TXA) is not recommended as a primary treatment to stop a lower GI bleed due to limited evidence of its effectiveness in this context. The management of lower GI bleeding typically involves identifying and treating the underlying cause through endoscopic interventions, angiographic embolization, or surgery, depending on the severity and source of bleeding 1. Initial management should focus on hemodynamic stabilization with intravenous fluids and blood transfusions if needed, along with prompt diagnostic evaluation using colonoscopy or other imaging modalities.
While TXA has been recommended for patients with mild GI bleeding due to its low potential for harm, the evidence supporting its use is limited 1. In fact, systemic therapies such as bevacizumab are recommended for patients with moderate or severe GI bleeding, as they have shown substantial improvements in mean hemoglobin levels and reduced the need for red cell transfusions 1. The pathophysiology of lower GI bleeding, which often involves diverticular disease, angiodysplasia, or inflammatory bowel conditions, suggests that systemic antifibrinolytics like TXA may not effectively target the bleeding source.
Key considerations in managing lower GI bleeding include:
- Hemodynamic stabilization
- Prompt diagnostic evaluation
- Endoscopic interventions or other treatments targeting the underlying cause
- Use of systemic therapies like bevacizumab for moderate or severe bleeding, as supported by recent guidelines 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.