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

Tranexamic Acid (TXA) for Gastrointestinal Bleeding

Tranexamic acid should not be used for gastrointestinal bleeding as it does not reduce mortality or rebleeding and increases the risk of thromboembolic events. 1

Evidence on TXA for GI Bleeding

The evidence regarding TXA for GI bleeding shows different outcomes based on dosing strategy and type of bleeding:

High-Dose IV TXA (4g/24h or greater)

• No mortality benefit: High-quality evidence from five studies, including the large HALT-IT trial, found no difference in mortality (RR 0.98,95% CI 0.88-1.09) 1
• No reduction in rebleeding: High-dose TXA did not reduce rebleeding (RR 0.92,95% CI 0.82-1.04) 1
• No reduction in need for surgical intervention: (RR 0.91,95% CI 0.76-1.09) 1
• Increased adverse events: High-dose TXA significantly increased:
  • Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72) 1
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 1
  • Seizures (RR 1.73,95% CI 1.03-2.93) 1

Low-Dose IV/Enteral TXA

• May reduce rebleeding (RR 0.5,95% CI 0.38-0.88) 1
• May reduce need for surgical intervention (RR 0.58,95% CI 0.38-0.88) 1
• Possible reduction in mortality, but evidence is imprecise (RR 0.62,95% CI 0.36-1.09) 1
• Limited data on adverse events in these studies 1

Special Considerations for Different Types of GI Bleeding

Variceal Bleeding

• TXA is specifically contraindicated in variceal bleeding: The European Society of Intensive Care Medicine strongly recommends against TXA use in patients with cirrhosis and active variceal bleeding 1
• In patients with liver disease/suspected variceal bleeding, TXA showed:
  • No beneficial effect on bleeding control 1
  • Almost 2-fold increase in venous thromboembolic events 1

Portal Hypertensive Bleeding

• For bleeding related to portal hypertension but not varices (e.g., portal hypertensive gastropathy), management should focus on portal hypertension-lowering measures rather than hemostatic agents 1

Lower GI Bleeding

• The British Society of Gastroenterology suggests that use of TXA in acute lower GI bleeding should be confined to clinical trials 1
• Evidence for TXA in lower GI bleeding is particularly limited and requires further clarification 2

Clinical Approach to GI Bleeding

Instead of TXA, focus on established treatments:

1. For upper GI bleeding:

   • Prompt initiation of vasoactive therapy (terlipressin, somatostatin, or octreotide)
   • Early endoscopic intervention
   • Acid suppression therapy
   • Antibiotics when indicated (especially in cirrhosis)

2. For lower GI bleeding:

   • Resuscitation and hemodynamic stabilization
   • Early colonoscopy when appropriate
   • Interventional radiology for persistent bleeding
   • Surgical intervention when other methods fail

3. For variceal bleeding:

   • Vasoactive drugs
   • Endoscopic band ligation
   • Portal pressure-lowering measures
   • Avoid TXA due to increased thrombotic risk 1

Common Pitfalls

1. Using TXA based on extrapolation from trauma data: Despite TXA's proven benefit in trauma and surgical bleeding, this does not translate to GI bleeding 1

2. Ignoring thrombotic risk: The increased risk of thromboembolic events with TXA in GI bleeding patients outweighs potential benefits 1

3. Failing to distinguish between types of GI bleeding: The approach to variceal, non-variceal upper GI, and lower GI bleeding differs significantly

4. Overlooking the primary cause: Focus should be on treating the underlying cause rather than attempting to achieve hemostasis with TXA

In conclusion, current high-quality evidence does not support the use of TXA for GI bleeding in routine clinical practice. Management should focus on established treatments targeting the underlying cause of bleeding.