Tranexamic Acid for Upper GI Bleeding
Tranexamic acid (TXA) is not recommended for the treatment of upper gastrointestinal bleeding, particularly in patients with suspected variceal bleeding or liver disease, as it shows no benefit and may increase the risk of venous thromboembolic events. 1
Evidence Assessment
Current Guidelines on TXA for GI Bleeding
The most recent and highest quality evidence comes from the European Association for the Study of the Liver (EASL) 2022 clinical practice guidelines, which strongly recommend against using tranexamic acid in patients with cirrhosis and active variceal bleeding 1. This recommendation is based on a large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding (the HALT-IT trial), which showed:
- No beneficial effect of tranexamic acid on mortality or bleeding control
- An almost 2-fold increase in venous thromboembolic events in the tranexamic acid group
- Higher risk of thrombotic events specifically concentrated in patients with liver disease/suspected variceal bleeding 1
The British Society of Gastroenterology (BSG) 2019 guidelines similarly suggest that tranexamic acid use in acute GI bleeding should be confined to clinical trials 1.
Reasons for TXA Ineffectiveness in Upper GI Bleeding
Several factors explain why TXA is ineffective for upper GI bleeding:
- Pathophysiology mismatch: The limited role of fibrinolysis in variceal bleeding mechanisms 1
- Hypofibrinolytic state: Critically ill patients with cirrhosis often have a hypofibrinolytic state, making antifibrinolytics unnecessary or potentially harmful 1
- Portal pressure effects: Administration of blood products can increase portal pressure, potentially worsening outcomes in patients with portal hypertension 1
Management Recommendations for Upper GI Bleeding
Instead of TXA, current guidelines recommend:
For Variceal Bleeding
- Prompt initiation of vasoactive therapy (terlipressin, somatostatin, or octreotide) before endoscopy
- Prophylactic antibiotics
- Endoscopic band ligation (EBL) 1
- Restrictive red blood cell transfusion strategy 1
For Non-Variceal Upper GI Bleeding
- High-dose proton pump inhibitors (80 mg stat followed by an infusion of 8 mg hourly for 72 hours) following successful endoscopic therapy 1
- Endoscopic therapy as the primary intervention
- Restrictive transfusion strategies
Historical Context and Conflicting Evidence
While some older and smaller studies suggested potential benefits of TXA in upper GI bleeding 2, 3, 4, 5, these findings have been superseded by more recent, larger, and higher-quality trials. The American Association for the Study of Liver Diseases (AASLD) 2021 practice guidance specifically states that "until further supportive data are published, the prophylactic use of EACA or tranexamic acid to prevent procedural bleeding cannot be recommended" 1.
Special Considerations
For patients with liver disease, the risk of thrombotic complications with TXA appears to be particularly elevated 1. This is counterintuitive given the traditional view of coagulopathy in liver disease but aligns with our current understanding of rebalanced hemostasis in these patients.
Conclusion
Based on the most recent and highest quality evidence, TXA should not be used to stop upper GI bleeding, especially in patients with suspected variceal bleeding or liver disease. The standard of care remains prompt endoscopic intervention combined with appropriate pharmacological therapy (vasoactive drugs for variceal bleeding or proton pump inhibitors for non-variceal bleeding).