From the Guidelines
Tranexamic acid (TXA) should not be used to stop an upper gastrointestinal (GI) bleed, particularly in patients with cirrhosis and variceal bleeding, due to the lack of beneficial effect and potential increased risk of venous thromboembolic events. The use of TXA in this context is not supported by recent evidence, including a large randomized placebo-controlled trial that found no beneficial effect of TXA in patients with acute upper gastrointestinal bleeding, including those with suspected variceal bleeding and liver disease comorbidity 1. In fact, the study found an almost 2-fold increase in the incidence of venous thromboembolic events in the TXA group compared to the placebo group.
The current guidelines recommend against the use of TXA in patients with cirrhosis and active variceal bleeding, with a strong recommendation based on level 2 evidence 1. The standard therapy for variceal bleeding includes prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment, with a focus on correcting portal hypertension rather than haemostatic abnormalities.
Some key points to consider when managing upper GI bleeding include:
- The importance of prompt endoscopic intervention to directly treat the bleeding source
- The use of vasoactive therapy, such as terlipressin, somatostatin, or octreotide, to reduce portal pressure
- The administration of antibiotics to prevent infection
- The potential risks and benefits of blood product transfusions, including the risk of increasing portal pressure and worsening outcomes.
Overall, the management of upper GI bleeding requires a multifaceted approach that prioritizes endoscopic intervention, correction of portal hypertension, and careful consideration of the risks and benefits of various treatments, including TXA.
From the Research
Tranexamic Acid (TXA) in Upper GI Bleed Management
- There is no direct evidence in the provided studies to suggest that tranexamic acid (TXA) can stop an upper gastrointestinal (GI) bleed 2, 3, 4, 5, 6.
- The management of upper GI bleeding typically involves resuscitation with fluids and blood products, endoscopy, and the use of proton pump inhibitors and prokinetic agents 2, 3, 4, 5.
- Endoscopic therapy, including injection, thermal, and mechanical methods, is commonly used to achieve hemostasis in patients with upper GI bleeding 2, 3, 5.
- In cases where endoscopic therapy is unsuccessful, other interventions such as transcatheter arterial embolization or surgery may be considered 3, 5.
Current Treatment Options
- Proton pump inhibitors are the mainstay of pharmacologic treatment for upper GI bleeding, and are typically initiated upon presentation 3, 4, 5.
- Endoscopy should be performed within 24 hours of presentation, and earlier in patients with hemodynamic instability 2, 3, 5.
- The use of antithrombotic agents, such as tranexamic acid, is not mentioned in the context of upper GI bleed management in the provided studies 2, 3, 4, 5, 6.