Can tranexamic acid (TXA) stop an upper gastrointestinal (GI) bleed?

Tranexamic Acid for Upper GI Bleeding

Tranexamic acid (TXA) is not recommended for routine use in upper GI bleeding as it does not reduce mortality and is associated with increased risk of thromboembolic events, particularly in patients with liver disease. 1

Evidence Assessment

The evidence regarding TXA for upper GI bleeding shows mixed results:

• The most recent guidelines from the British Society of Gastroenterology (2019) state that TXA should be confined to clinical trials, pending results of the HALT-IT trial 2
• The 2022 EASL guidelines specifically recommend against TXA use in variceal bleeding (strong recommendation) 2
• The HALT-IT trial (referenced in the 2021 guidelines) showed no mortality benefit with a relative risk of 0.99 and increased thromboembolic events with a relative risk of 1.85 1
• Older meta-analyses suggested potential benefits, but these were based on smaller, lower quality studies 2, 3

Management Algorithm for Upper GI Bleeding

First-Line Treatments (Proven Effective)

1. Proton Pump Inhibitors

   • High-dose IV omeprazole (80 mg stat followed by 8 mg/hour infusion for 72 hours) is recommended following successful endoscopic therapy 2
   • This has demonstrated reduced rebleeding rates, blood transfusion requirements, and hospital stay duration

2. Endoscopic Therapy

   • Early endoscopic diagnosis and intervention remain the cornerstone of management
   • Repeat endoscopy should be performed for clinical evidence of rebleeding 2

3. Blood Product Management

   • Use restrictive transfusion strategy (hemoglobin threshold of 70 g/L)
   • Higher thresholds may be appropriate for patients with cardiovascular disease 1

Second-Line Options

1. Somatostatin

   • May be considered in select cases, though evidence quality is poor 2
   • Works by reducing splanchnic blood flow and suppressing acid secretion

2. Interventional Radiology

   • For ongoing bleeding not controlled by endoscopic therapy 1

3. Surgical Intervention

   • Consider for uncontrolled hemorrhage after failed endoscopic and radiological approaches 1

Why TXA Is Not Recommended

Despite some earlier promising meta-analyses 3, 4, the most recent and highest quality evidence does not support TXA use:

1. Lack of Mortality Benefit

   • Meta-analyses show inconsistent results on mortality reduction 5
   • The HALT-IT trial (largest RCT) found no significant mortality benefit 6

2. Thromboembolic Risk

   • Increased risk of venous thromboembolic events, particularly in patients with liver disease 2, 1
   • Risk is almost doubled (RR 1.85) compared to placebo 1

3. Limited Effect on Rebleeding

   • While some studies suggest reduced rebleeding 3, 5, the effect is inconsistent
   • A 2021 RCT of locally administered TXA showed no benefit over standard care 7

4. Specific Contraindication in Variceal Bleeding

   • Strongly contraindicated in variceal bleeding due to:
     • Limited role of hemostasis in variceal bleeding
     • Hypofibrinolytic state in critically ill cirrhosis patients 2

Special Considerations

• Liver Disease: TXA is specifically contraindicated in patients with cirrhosis and variceal bleeding due to increased thromboembolic risk 2
• Timing: Even in trauma settings where TXA is beneficial, early administration is critical - this window may be missed in many GI bleeding presentations
• Local vs. Systemic Administration: Local TXA administration has not shown benefit over standard care 7

The current standard of care for upper GI bleeding should focus on proven interventions including endoscopic therapy, proton pump inhibitors, and appropriate blood product management rather than TXA.