Can Tranexamic acid (TXA) stop a gastrointestinal (GI) bleed?

Tranexamic Acid (TXA) Is Not Recommended for GI Bleeding

High-dose intravenous TXA should not be used for gastrointestinal bleeding as it increases thrombotic complications without improving mortality or rebleeding rates. While low-dose or enteral TXA shows some potential benefit, current evidence does not support its routine use.

Evidence Against High-Dose IV TXA in GI Bleeding

The European Society of Intensive Care Medicine (ESICM) explicitly recommends against using high-dose IV TXA in critically ill patients with gastrointestinal bleeding based on high-certainty evidence 1. This recommendation is supported by multiple clinical trials, including the large HALT-IT trial, which found:

• No reduction in mortality (RR 0.98,95% CI 0.88–1.09)
• No reduction in rebleeding (RR 0.92,95% CI 0.82–1.04)
• No reduction in need for surgical intervention (RR 0.91,95% CI 0.76–1.09)
• Increased rates of deep vein thrombosis (RR 2.10,95% CI 1.08–3.72)
• Increased rates of pulmonary embolism (RR 1.78,95% CI 1.06–3.0)
• Increased rates of seizures (RR 1.73,95% CI 1.03–2.93) 1

The British Society of Gastroenterology (BSG) similarly suggests that TXA use in acute LGIB should be confined to clinical trials 1, while the American Association for the Study of Liver Diseases (AASLD) notes increased risk of venous thromboembolism in patients with cirrhosis receiving TXA 1.

Low-Dose/Enteral TXA: Uncertain Evidence

For low-dose IV or enteral TXA, the ESICM makes no recommendation due to moderate certainty evidence 1. Some studies suggest potential benefits:

• Possible reduction in rebleeding (RR 0.5,95% CI 0.38–0.88)
• Possible reduction in need for surgical intervention (RR 0.58,95% CI 0.38–0.88)
• Possible reduction in mortality (RR 0.62,95% CI 0.36–1.09) 1

However, these results are limited by imprecision, and data on potential harms were not adequately reported in most trials.

Special Considerations for Specific Patient Populations

Patients with Cirrhosis

The European Association for the Study of the Liver (EASL) strongly recommends against using TXA in patients with cirrhosis and active variceal bleeding 1. In these patients, standard therapy should include:

1. Prompt initiation of vasoactive therapy (terlipressin, somatostatin, or octreotide)
2. Antibiotics
3. Endoscopic band ligation 1

Patients with Hereditary Hemorrhagic Telangiectasia (HHT)

For patients with HHT and GI bleeding, tranexamic acid is recommended only for mild GI bleeding due to limited evidence of effectiveness 1.

Recent Meta-Analyses: Mixed Results

Recent meta-analyses show conflicting results:

• A 2025 meta-analysis found TXA significantly reduced rebleeding rates overall (RR: 0.81,95% CI: 0.87-0.97) and was associated with mortality reduction in upper GI bleeding (RR: 0.72,95% CI: 0.59-0.87), but increased mortality in lower GI bleeding (RR: 1.67,95% CI: 1.44-1.93) 2.

• A 2022 meta-analysis confirmed that high-dose IV TXA does not improve mortality or bleeding outcomes and increases adverse events, while low-dose/enteral TXA may reduce hemorrhage but requires more safety evidence 3.

Conclusion

Based on the highest quality and most recent evidence, TXA should not be used for GI bleeding management. The potential harms (thrombotic events and seizures) outweigh the unproven benefits. Standard management of GI bleeding should focus on:

1. Prompt resuscitation
2. Early endoscopy for diagnosis and treatment
3. Appropriate use of vasoactive drugs for variceal bleeding
4. Interventional radiology or surgery when indicated

If bleeding persists despite standard measures, the decision to use TXA should be made on a case-by-case basis, with careful consideration of thrombotic risk factors and in consultation with specialists.