Can tranexamic acid (TXA) stop a lower gastrointestinal (GI) bleed?

Tranexamic Acid for Lower GI Bleeding

Tranexamic acid (TXA) is not recommended for the treatment of lower GI bleeding due to lack of mortality benefit and increased risk of thromboembolic events. 1

Evidence Against TXA Use in Lower GI Bleeding

The most recent and highest quality evidence from Praxis Medical Insights (2025) clearly indicates that TXA:

• Shows no reduction in mortality (RR 0.98,95% CI 0.88-1.09) for GI bleeding
• Shows no significant reduction in rebleeding (RR 0.92,95% CI 0.82-1.04)
• Significantly increases risk of thrombotic complications:
  • Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72)
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0)
  • Seizures (RR 1.73,95% CI 1.03-2.93) 1

A specific randomized controlled trial examining TXA for lower GI hemorrhage found no difference in blood loss as determined by hemoglobin drop (11 g/L with TXA vs 13 g/L with placebo; p = 0.9445), and no improvements in transfusion rates, intervention rates, or length of hospital stay 2.

Recommended Management for Lower GI Bleeding

Instead of TXA, the following approach is recommended for lower GI bleeding:

1. Initial assessment and stabilization:

   • Assess hemodynamic stability
   • Use a restrictive transfusion threshold of 70 g/L (aiming for 70-100 g/L)
   • Consider a higher threshold for patients with cardiovascular disease 3

2. Diagnostic approach:

   • For hemodynamically unstable patients or those with shock index >1, perform CT angiography to localize bleeding 3
   • Consider upper endoscopy if brisk rectal bleeding with hemodynamic instability is present, as 10-15% of apparent lower GI bleeds are actually upper GI sources 3

3. Definitive management:

   • Early colonoscopy (within 24 hours after adequate bowel preparation) for diagnosis and potential therapeutic intervention 4
   • Endoscopic hemostasis for high-risk stigmata (active bleeding, non-bleeding visible vessel, adherent clot)
   • Consider interventional radiology for ongoing bleeding not responding to endoscopic therapy 3

Special Considerations

• TXA is absolutely contraindicated in patients with recent thrombosis 1
• TXA has relative contraindications in patients with atrial fibrillation and known thrombophilia 1
• TXA is specifically contraindicated in patients with cirrhosis and variceal bleeding due to increased thromboembolic risk 1

Pitfalls to Avoid

1. Don't assume all rectal bleeding is from a lower GI source: Up to 15% of patients with hematochezia have an upper GI source 3

2. Don't delay appropriate intervention: For unstable patients, CT angiography provides the fastest means to localize bleeding before planning endoscopic or radiological therapy 3

3. Don't use TXA routinely: Despite some positive results in smaller studies, the most recent high-quality evidence shows no mortality benefit and increased thromboembolic risk 1

4. Don't forget to manage anticoagulation appropriately: For patients on anticoagulants, interrupt therapy at presentation and consider specific reversal agents for life-threatening hemorrhage 1

While some case reports suggest TXA might be beneficial in specific scenarios like Jehovah's Witness patients refusing blood products 5, the current highest quality evidence does not support its routine use for lower GI bleeding due to lack of efficacy and increased thrombotic risk.