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 gastrointestinal bleeding due to lack of proven efficacy and potential increased risk of thromboembolic events. 1

Evidence Assessment

The most recent and authoritative guideline from Praxis Medical Insights (2025) explicitly recommends against the routine use of TXA for GI bleeding, citing:

• Lack of mortality benefit
• Increased risk of thromboembolic events (relative risk of 1.85,95% CI 1.15-2.98) compared to placebo 1
• Specific contraindications in patients with recent thrombosis, atrial fibrillation, and known thrombophilia 1

This recommendation is supported by other evidence:

• The British Society of Gastroenterology (2019) guidelines state that "use of tranexamic acid in acute LGIB is confined to clinical trials" 2
• A randomized controlled trial specifically examining TXA for lower GI hemorrhage found no difference in blood loss (measured by hemoglobin drop) between TXA and placebo groups 3
• The same trial showed no improvement in transfusion rates, intervention rates, or length of hospital stay 3

Management Algorithm for Lower GI Bleeding

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

1. Initial assessment and stabilization:

   • Use a restrictive transfusion threshold of 70 g/L (aiming for 70-100 g/L) 2
   • Consider a higher threshold for patients with cardiovascular disease 2

2. Diagnostic approach:

   • For hemodynamically unstable patients: CT angiography to localize bleeding 2, 1
   • Rule out upper GI source (10-15% of apparent lower GI bleeds are actually upper GI sources) 1
   • Early colonoscopy (within 24 hours after adequate bowel preparation) 1, 4

3. Therapeutic interventions:

   • Endoscopic hemostasis for high-risk stigmata (active bleeding, non-bleeding visible vessel, adherent clot) 1
   • Consider interventional radiology for ongoing bleeding not responding to endoscopic therapy 1
   • Surgical intervention for uncontrolled hemorrhage after failed endoscopic and radiological approaches 1

Special Considerations

• For patients on anticoagulants: interrupt direct oral anticoagulants at presentation 1
• For life-threatening hemorrhage on DOACs: consider specific reversal agents like idarucizumab (for dabigatran) or andexanet alfa (for factor Xa inhibitors) 1
• Restart anticoagulation approximately 7 days after hemorrhage if the bleeding source has been controlled 1

Common Pitfalls

1. Assuming TXA is beneficial: Despite its effectiveness in trauma and postpartum hemorrhage, TXA has not shown benefit in lower GI bleeding and may increase thromboembolic risk.

2. Missing an upper GI source: Up to 15% of patients with apparent lower GI bleeding actually have an upper GI source, particularly those with hemodynamic instability 1.

3. Delaying endoscopy: Early colonoscopy (within 24 hours) after adequate bowel preparation improves diagnostic and therapeutic yield 1, 4.

4. Inappropriate transfusion: Nearly one-third of patients with lower GI bleeding receive RBC transfusions, but up to 80% of these may be inappropriate or unnecessary 2.

While there are isolated case reports of TXA use in specific scenarios such as Jehovah's Witness patients refusing blood products 5, the current evidence does not support its routine use for lower GI bleeding.