Is tranexamic acid (TXA) beneficial in diverticular or rectal variceal bleeding?

Tranexamic Acid in Diverticular or Rectal Variceal Bleeding

Tranexamic acid (TXA) should not be used in rectal variceal bleeding and is not recommended for diverticular bleeding based on current evidence.

Rectal Variceal Bleeding

Evidence Against TXA Use

• The European Association for the Study of the Liver (EASL) strongly recommends against using tranexamic acid in patients with cirrhosis and active variceal bleeding (Level of Evidence 2, strong recommendation) 1.
• In patients with portal hypertension-related bleeding, including rectal varices, portal hypertension-lowering measures should be the primary approach rather than TXA 1, 2.
• High-dose IV TXA has been associated with increased risk of venous thromboembolic events in patients with liver disease/suspected variceal bleeding 1.

Recommended Management for Rectal Variceal Bleeding

1. First-line treatments:

   • Vasoactive medications (terlipressin, somatostatin, octreotide) 1
   • Portal hypertension-lowering measures 1
   • Local endoscopic procedures when feasible

2. If first-line fails:

   • Consider a "step-up" approach with radiological and then surgical procedures 1
   • Embolization via interventional radiological techniques for short-term control 1
   • TIPS (transjugular intrahepatic portosystemic shunt) to decompress the portal venous system in patients with severe portal hypertension 1

Diverticular Bleeding

Evidence Regarding TXA Use

• High-dose IV TXA (1g loading + 3g over 24h) does not improve mortality or bleeding outcomes in general GI bleeding and increases adverse events including:

  • Deep vein thrombosis (RR 2.01; 95% CI 1.08-3.72) 3
  • Pulmonary embolism (RR 1.78; 95% CI 1.06-3.0) 3
  • Seizures (RR 1.73; 95% CI 1.03-2.93) 3, 4

• The HALT-IT trial (n=12,009) showed no benefit of TXA in reducing death due to bleeding in GI bleeding patients (RR 0.99,95% CI 0.82-1.18) 4.

Alternative Management for Diverticular Bleeding

1. First-line approach:

   • Resuscitation with restrictive blood transfusion strategy (target Hb 7-9 g/dl) 2
   • Endoscopic identification and treatment of the bleeding source
   • High-dose proton pump inhibitor therapy 2

2. If bleeding persists:

   • Repeat endoscopy 2
   • Consider radiological intervention (angiographic embolization) for persistent bleeding not amenable to endoscopic control 2
   • Surgical intervention if other measures fail 2

Special Considerations

Potential Limited Role for Low-Dose TXA

• Some evidence suggests low-dose IV/enteral TXA may reduce risk of rebleeding (RR 0.5; 95% CI 0.33-0.75) and need for surgery (RR 0.58; 95% CI 0.38-0.88) in non-variceal GI bleeding 3.
• A small study in dialysis patients with upper GI bleeding showed benefits of low-dose TXA in decreasing early re-bleeding and need for blood transfusions 5.

Important Contraindications and Precautions

• TXA is contraindicated in disseminated intravascular coagulation (DIC) 2
• Use with caution in patients with:
  • Renal dysfunction (increased risk of neurotoxicity) 2
  • Massive hematuria (risk of ureteric obstruction) 2
  • Patients on oral contraceptive pills (increased thrombosis risk) 2

Conclusion

For rectal variceal bleeding, focus on portal hypertension-lowering measures and avoid TXA. For diverticular bleeding, standard endoscopic and medical management is preferred over TXA given the lack of mortality benefit and increased risk of thromboembolic events with high-dose TXA regimens.