What is the role of tranexamic acid (TXA) in managing middle gastrointestinal (GI) bleeding?

Tranexamic Acid in Middle Gastrointestinal Bleeding

Tranexamic acid should not be used for the treatment of middle gastrointestinal bleeding due to lack of mortality benefit and increased risk of thromboembolic events. 1

Evidence Against TXA Use in GI Bleeding

The evidence strongly discourages the use of tranexamic acid (TXA) in gastrointestinal bleeding, including middle GI bleeding, for the following reasons:

• The European Society of Intensive Care Medicine makes a conditional recommendation against using high-dose IV TXA in critically ill patients with gastrointestinal bleeding, based on high-certainty evidence 1
• Extended-use high-dose IV tranexamic acid does not reduce mortality (RR 0.98,95% CI 0.88-1.09) or bleeding outcomes (RR 0.92,95% CI 0.82-1.04) 2
• TXA significantly increases the risk of thromboembolic events:
  • Deep venous thrombosis (RR 2.01,95% 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) 2

The HALT-IT trial, a large international randomized controlled trial including 12,009 patients, conclusively demonstrated that TXA did not reduce death from gastrointestinal bleeding but increased venous thromboembolic events (RR 1.85; 95% CI 1.15 to 2.98) 3.

Special Considerations in Patients with Liver Disease

For patients with cirrhosis and middle GI bleeding:

• The European Association for the Study of the Liver (EASL) specifically discourages the routine use of tranexamic acid to decrease procedure-related bleeding in patients with cirrhosis 4
• In patients with cirrhosis and active bleeding related to portal hypertension, bleeding should be managed with portal hypertension-lowering measures rather than TXA 4
• Patients with liver disease have an increased risk of thromboembolic events with TXA use 1

Alternative Evidence-Based Management Approaches

Instead of TXA, the following approaches are recommended for middle GI bleeding:

1. Resuscitation and hemodynamic stabilization:

   • Target hemoglobin of 70-90 g/L 1
   • Restrictive packed red blood cell transfusions (transfusion with hemoglobin <7 g/dl with a target hemoglobin of 7-9 g/dl) 4

2. Early endoscopic intervention when appropriate 1

3. For portal hypertension-related bleeding:

   • Portal hypertension-lowering measures as the primary approach 4, 1
   • Prompt initiation of vasoactive therapy and antibiotics for variceal bleeding 1

4. For patients on anticoagulants:

   • Withhold the anticoagulant
   • Resuscitate the patient
   • Consider specific reversal agents for severe bleeding with DOACs 1

Low-Dose TXA: Insufficient Evidence

While some smaller studies suggest low-dose IV or enteral TXA may reduce rebleeding (RR 0.5,95% CI 0.38-0.88) and need for surgical intervention (RR 0.58,95% CI 0.38-0.88), these results are limited by imprecision and lack of data on potential harms 1, 2. The European Society of Intensive Care Medicine makes no recommendation regarding low-dose IV or enteral TXA due to this uncertainty 1.

Common Pitfalls to Avoid

1. Do not use TXA based on its benefits in trauma patients - While TXA has proven benefits in trauma patients with bleeding when administered within 3 hours of injury, this benefit does not extend to GI bleeding 1

2. Do not administer large volumes of blood products unnecessarily - In patients with cirrhosis, transfusion of blood products can increase portal pressure by increasing blood volume, thus potentially increasing the risk of further bleeding 4

3. Do not neglect monitoring for adverse events if TXA is used despite recommendations - Monitor for thromboembolic complications and seizures 1

In conclusion, current high-quality evidence does not support the use of tranexamic acid in the management of middle gastrointestinal bleeding due to lack of mortality benefit and increased risk of thromboembolic events.