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

Tranexamic Acid for Gastrointestinal Bleeding

High-dose intravenous tranexamic acid (TXA) should not be used for gastrointestinal bleeding as it shows no benefit in reducing mortality or rebleeding while increasing the risk of thrombotic events and seizures. 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 based on high-certainty evidence 1
• The large HALT-IT trial and other studies found:
  • 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 adverse events with high-dose IV TXA:
  • Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72) 1
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.00) 1
  • Seizures (RR 1.73,95% CI 1.03-2.93) 1

Low-Dose IV/Enteral TXA

• The ESICM makes no recommendation regarding low-dose IV or enteral TXA due to moderate-certainty evidence 1
• Some 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), though this is imprecise 1

Special Considerations for Variceal Bleeding

• For patients with cirrhosis and variceal bleeding, TXA should not be used (Level of Evidence 2, strong recommendation) 1
• In cirrhotic patients with suspected variceal bleeding, TXA showed:
  • No beneficial effect on mortality 1
  • Almost 2-fold increase in venous thromboembolic events 1
• This may be due to:
  • Limited role of hemostasis in variceal bleeding 1
  • Frequent hypofibrinolytic state in critically ill cirrhotic patients 1

Recent Research Findings

A 2024 randomized controlled trial specifically examining TXA in lower GI bleeding found no significant effect on blood transfusion requirements 2. This reinforces the guidelines' recommendations against routine use of TXA in GI bleeding.

Some older or smaller studies suggested potential benefits of TXA in upper GI bleeding 3, 4, but these findings have been superseded by the larger, more recent HALT-IT trial that showed no mortality benefit with increased thrombotic complications.

Clinical Approach to GI Bleeding

Instead of TXA, management should focus on:

1. Prompt resuscitation
2. Early endoscopy for diagnosis and treatment
3. Specific therapies based on bleeding etiology:
   • For variceal bleeding: vasoactive drugs (terlipressin, somatostatin, octreotide), antibiotics, and endoscopic band ligation 1
   • For portal hypertensive gastropathy: portal hypertension-lowering measures 1

Pitfalls and Caveats

1. Thrombotic risk: The increased risk of venous thromboembolism with high-dose TXA is particularly concerning in patients with liver disease 1

2. Timing considerations: While TXA has shown benefit in trauma when given early, this benefit does not extend to GI bleeding 1

3. Portal pressure effects: In cirrhotic patients, administration of blood products can increase portal pressure, potentially worsening bleeding outcomes 1

4. Dosing confusion: Do not extrapolate from trauma protocols where TXA is beneficial - the pathophysiology of GI bleeding is different 1

In conclusion, current high-quality evidence does not support the use of high-dose IV TXA for GI bleeding, and there is insufficient evidence to recommend low-dose or enteral TXA. Management should focus on established treatments including endoscopic therapy, vasoactive drugs for variceal bleeding, and appropriate resuscitation.