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

Tranexamic Acid (TXA) for Lower Gastrointestinal Bleeding

Tranexamic acid is not recommended for the treatment of lower gastrointestinal bleeding as it does not appear to decrease blood loss or improve clinical outcomes in this condition. 1, 2

Evidence Against TXA in Lower GI Bleeding

The most recent and highest quality evidence demonstrates that TXA is ineffective for lower GI bleeding:

• A 2024 double-blind randomized controlled trial specifically examining TXA in lower GI bleeding found no significant effect on blood transfusion requirements compared to placebo 2
• A 2018 randomized placebo-controlled trial showed no difference in hemoglobin drop, transfusion rates, transfusion volume, intervention rates, or length of hospital stay when TXA was used for lower GI bleeding 1

Guideline Recommendations

Current guidelines do not support TXA use in GI bleeding:

• The British Society of Gastroenterology strongly recommends against using tranexamic acid for gastrointestinal bleeding in routine clinical practice 3
• The European Association for the Study of the Liver (EASL) specifically advises against TXA use in patients with cirrhosis and active bleeding 3
• TXA is contraindicated in patients with liver disease due to a nearly 2-fold increase in venous thromboembolic events with no mortality benefit 3

Recommended Management for Lower GI Bleeding

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

Initial Assessment and Resuscitation

• Assess hemodynamic status and initiate intravascular volume resuscitation as needed 4
• Use a restrictive red blood cell transfusion strategy with a threshold of 70 g/L, aiming for a target of 70-100 g/L 5
• Consider a higher transfusion threshold in patients with cardiovascular disease 5

Diagnostic Approach

• For hemodynamically unstable patients (shock index >1) or those with suspected active bleeding, CT angiography should be the first-line investigation 5
• If no source is identified by initial CTA and the patient remains unstable, perform upper endoscopy immediately to exclude an upper GI source 5
• If the patient stabilizes after initial resuscitation, colonoscopy should be performed within 24 hours after adequate bowel preparation 4

Interventions

• Provide endoscopic hemostasis therapy to patients with high-risk endoscopic stigmata of bleeding 4
• Consider radiographic interventions (tagged RBC scintigraphy, CT angiography, angiography) in high-risk patients with ongoing bleeding who don't respond to resuscitation 4

Special Considerations

While TXA may have a role in other types of bleeding (trauma, postpartum hemorrhage), its use in GI bleeding should be limited to clinical trials 3. The only potential exception might be in cases where blood products are refused (e.g., Jehovah's Witness patients) as suggested by limited case report evidence 6, but this remains outside standard practice recommendations.

Pitfalls to Avoid

• Do not assume lower GI bleeding is truly from a lower source - up to 15% of patients with severe hematochezia may have an upper GI source 5
• Avoid delaying appropriate diagnostic procedures while attempting unproven pharmacological interventions like TXA
• Remember that TXA may increase the risk of venous thromboembolic events, particularly in patients with liver disease 3