What is the role of tranexamic acid (TXA) in the management of lower gastrointestinal (GI) bleeding?

From the Guidelines

Tranexamic acid (TXA) is not recommended for stopping a lower GI bleed due to the lack of high-quality evidence supporting its efficacy in this context. The management of lower gastrointestinal bleeding is complex and typically involves a multidisciplinary approach, including hemodynamic resuscitation, diagnostic evaluation, and endoscopic, radiologic, or surgical therapy 1. While TXA has been shown to be effective in treating upper GI bleeds by inhibiting fibrinolysis and stabilizing blood clots, its role in lower GI bleeding is not well established.

Key Considerations

• The standard management for lower GI bleeding includes:
  • Volume resuscitation with IV fluids and blood products as needed
  • Correction of coagulopathy
  • Endoscopic evaluation and intervention
  • Radiological interventions, such as angiography
  • Surgery, depending on the severity and source of bleeding
• The pathophysiological processes causing bleeding in the lower GI tract may differ from those in the upper GI tract, which could limit the effectiveness of TXA in this context.
• If TXA is considered for any GI bleeding, typical dosing is 1g IV every 6-8 hours, but this should only be done under specialist guidance given the limited evidence for lower GI bleeding.

Evidence Review

The review article by 1 highlights the paucity of high-quality evidence to guide the management of lower gastrointestinal bleeding, with current practices often reflecting local expertise and availability of services. While endoscopic and radiologic literature supports the role of urgent colonoscopy and angiography in the management of lower GI bleeding, there is limited evidence to support the use of TXA in this context.

Clinical Implications

Given the lack of evidence supporting the use of TXA for lower GI bleeding, clinicians should focus on established management strategies, including hemodynamic stabilization, diagnostic evaluation, and endoscopic or surgical intervention as needed. TXA may be considered in specific cases under specialist guidance, but its use should not be routine in the management of lower GI bleeding.

From the Research

Effectiveness of TXA in Lower GI Bleed

• The use of tranexamic acid (TXA) in lower gastrointestinal bleeding is still unclear, with limited and heterogeneous evidence 2.
• A randomized controlled trial found that TXA does not appear to decrease blood loss or improve clinical outcomes in patients presenting with lower GI hemorrhage 3.
• Another study suggested that early administration of TXA may be worth recommending for treating upper gastrointestinal bleeding, but its effects on lower gastrointestinal bleeding warrant further clarification 2.
• A systematic review and meta-analysis found that extended-use high-dose IV TXA did not reduce mortality or bleeding outcomes and increased adverse events, while low-dose IV/enteral TXA may be effective in reducing hemorrhage 4.

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 5.
• A risk score can be used to aid, but should not replace, clinician judgment in assessing the severity of lower GI bleeding 5.
• The European Society of Gastrointestinal Endoscopy (ESGE) recommends that patients with major acute lower gastrointestinal bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding 5.
• The ESGE also recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk 5.

TXA in Gastrointestinal Bleeding

• A systematic review and meta-analysis found that TXA is proposed as a treatment for gastrointestinal bleeding, but its effectiveness is still uncertain 4.
• The review found that low-dose IV/enteral TXA may be effective in reducing hemorrhage, but more evidence is required to demonstrate its safety 4.
• Another study found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding, but its effects on lower gastrointestinal bleeding are still unclear 2.