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

Tranexamic Acid (TXA) for Gastrointestinal Bleeding

High-dose intravenous tranexamic acid should not be used for gastrointestinal bleeding as it shows no benefit in reducing mortality or rebleeding while increasing the risk of thrombotic complications. 1

Evidence on TXA in GI Bleeding

High-Dose IV TXA

• The European Society of Intensive Care Medicine (ESICM) guidelines provide a conditional recommendation against using high-dose IV TXA (≥4g/24h) in GI bleeding 1
• Evidence from five studies, including the large HALT-IT trial, showed:
  • No reduction in mortality (RR 0.98,95% CI 0.88-1.09) 1
  • No reduction in 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 risk of adverse events:
  • 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 or Enteral TXA

• ESICM makes no recommendation regarding low-dose IV or enteral TXA due to limited evidence 1
• Seven smaller studies suggest potential benefits:
  • Possible reduction in rebleeding (RR 0.5,95% CI 0.38-0.88) 1
  • Possible reduction in need for surgical intervention (RR 0.58,95% CI 0.38-0.88) 1
  • Possible reduction in mortality (RR 0.62,95% CI 0.36-1.09) 1
• However, these results have moderate certainty evidence with significant imprecision

Special Considerations for Variceal Bleeding

For patients with cirrhosis and variceal bleeding, the European Association for the Study of the Liver (EASL) provides a strong recommendation against using tranexamic acid 1:

• A large randomized placebo-controlled trial showed no beneficial effect of TXA in variceal bleeding 1
• Almost 2-fold increase in venous thromboembolic events was observed in the TXA group compared to placebo 1
• Risk of thrombotic events was particularly concentrated in patients with liver disease/suspected variceal bleeding 1

Lower GI Bleeding

A recent (2024) randomized controlled trial specifically examining TXA in lower GI bleeding found:

• No significant effect on blood transfusion requirements 2
• No difference in consumption of packed red blood cell units between TXA and placebo groups 2

Clinical Algorithm for GI Bleeding Management

1. Identify the source and type of GI bleeding

   • Upper vs. lower GI source
   • Variceal vs. non-variceal bleeding
   • Presence of liver disease/cirrhosis

2. Do NOT use high-dose IV TXA for any GI bleeding

   • High-quality evidence shows no benefit and increased harm 1
   • Particularly avoid in patients with liver disease or suspected variceal bleeding 1

3. For non-variceal bleeding:

   • Focus on standard treatments:
     • Prompt endoscopic intervention
     • Proton pump inhibitors for upper GI bleeding
     • Blood product transfusion as needed using restrictive strategies

4. For variceal bleeding:

   • Absolutely avoid TXA (strong recommendation) 1
   • Use standard therapy: vasoactive drugs (terlipressin, somatostatin, octreotide), antibiotics, and endoscopic band ligation 1

Pitfalls and Caveats

• Avoid extrapolating trauma TXA protocols to GI bleeding: Despite TXA's benefits in trauma, these do not extend to GI bleeding 1
• Beware increased thrombotic risk: Particularly in patients with liver disease, TXA increases risk of venous thromboembolism 1
• Low-dose/enteral TXA remains investigational: While showing some promise in smaller studies, current guidelines make no recommendation for their use pending further research 1
• Portal hypertension considerations: In cirrhosis, administration of blood products can increase portal pressure, potentially worsening bleeding outcomes 1

In conclusion, while TXA is effective in other bleeding scenarios like trauma and surgical bleeding, current high-quality evidence does not support its use in GI bleeding, particularly at high doses, and it should be avoided in patients with variceal bleeding or liver disease.