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

Tranexamic Acid for Lower Gastrointestinal Bleeding

Tranexamic acid (TXA) is not recommended for the treatment of lower gastrointestinal bleeding as it has not been shown to reduce blood loss or improve clinical outcomes in this specific condition. 1, 2

Evidence Against TXA Use in Lower GI Bleeding

Recent high-quality evidence specifically examining TXA in lower GI bleeding has shown:

• A 2024 double-blind randomized controlled trial found that intravenous TXA had no significant effect on blood transfusion requirements in patients with lower GI bleeding 1
• A 2018 prospective, double-blind, placebo-controlled trial demonstrated no difference in hemoglobin drop, transfusion rates, intervention rates, or length of hospital stay when using TXA for lower GI bleeding 2

Current Guideline Recommendations

Major gastroenterology societies do not recommend TXA for GI bleeding:

• The British Society of Gastroenterology strongly recommends against using TXA for gastrointestinal bleeding in routine clinical practice 3
• The European Association for the Study of the Liver specifically advises against TXA in patients with cirrhosis and active variceal bleeding due to increased risk of venous thromboembolic events 3

Management Algorithm for Lower GI Bleeding

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

1. Initial assessment and resuscitation:

   • Hemodynamic stabilization with IV fluids 4
   • Restrictive red blood cell transfusion strategy (target Hb 70-100 g/L) for most patients 4
   • Higher transfusion threshold for patients with cardiovascular disease 4

2. Diagnostic workup:

   • CT angiography as first-line investigation in hemodynamically unstable patients (shock index >1) 4
   • Rule out upper GI source with gastroscopy if no source identified on CTA 4
   • Colonoscopy within 24 hours after adequate bowel preparation in stable patients 5

3. Therapeutic interventions:

   • Endoscopic hemostasis for high-risk stigmata (active bleeding, non-bleeding visible vessel, adherent clot) 5
   • Interventional radiology for ongoing bleeding not responding to endoscopic therapy 5
   • Surgery for selected cases with persistent or recurrent bleeding 5

Special Considerations

While TXA has shown benefit in upper GI bleeding in some studies 6, this benefit does not extend to lower GI bleeding based on the most recent evidence 1, 2. The pathophysiology and bleeding patterns differ between upper and lower GI sources, which may explain this discrepancy.

In exceptional circumstances (such as Jehovah's Witness patients refusing blood products), TXA might be considered as a rescue therapy when standard treatments are unavailable or refused 7, but this remains outside standard practice and is not supported by current evidence for routine use.