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

Tranexamic Acid for Lower GI Bleeding

Tranexamic acid (TXA) is not recommended for routine use in lower gastrointestinal bleeding as it has not been shown to reduce blood loss or improve clinical outcomes in this specific setting. 1

Evidence Assessment

Current Guidelines on Lower GI Bleeding Management

The British Society of Gastroenterology's 2019 guidelines on acute lower gastrointestinal bleeding do not recommend tranexamic acid for routine use in lower GI bleeding. The guidelines specifically state that "at this time we suggest that use of tranexamic acid in acute LGIB is confined to clinical trials, pending the results of the HALT-IT trial." 2

The guidelines instead focus on a structured approach to managing lower GI bleeding that includes:

• Initial resuscitation
• Risk assessment
• Diagnostic investigations (CT angiography for unstable patients)
• Endoscopic, radiological, or surgical interventions based on findings

TXA in Lower GI Bleeding: Clinical Trial Evidence

A randomized placebo-controlled trial specifically examining tranexamic acid for lower GI hemorrhage found:

• No difference in hemoglobin drop between TXA and placebo groups (11 g/L vs 13 g/L)
• No difference in transfusion rates (14/49 vs 16/47)
• No difference in intervention rates (7/49 vs 13/47)
• No difference in length of hospital stay (4.67 vs 4.74 days) 1

Meta-analyses on TXA in GI Bleeding

A 2022 meta-analysis examining TXA in gastrointestinal bleeding found that:

• Extended-use high-dose IV TXA did not reduce mortality or bleeding
• Extended-use high-dose IV TXA increased risk of deep venous thrombosis, pulmonary embolism, and seizures
• Low-dose IV/enteral TXA did not reduce mortality but may reduce rebleeding risk 3

Another meta-analysis from 2021 showed that while TXA appears effective for upper GI bleeding, "the effects of tranexamic acid on lower gastrointestinal bleeding warrant further clarification." 4

Recommended Management Approach for Lower GI Bleeding

1. Initial Assessment and Resuscitation:

   • Hemodynamic stabilization with IV fluids
   • Blood transfusion if hemoglobin <70 g/L (target 70-100 g/L) 2

2. Diagnostic Evaluation:

   • For hemodynamically unstable patients: CT angiography as first-line investigation 2
   • For stable patients: Colonoscopy after adequate bowel preparation

3. Therapeutic Options:

   • Endoscopic therapy for identified bleeding sources
   • Interventional radiology for ongoing bleeding not amenable to endoscopic treatment
   • Surgical intervention if other methods fail

Special Considerations

Anticoagulated Patients

For patients on anticoagulants with severe lower GI bleeding:

• Temporarily withhold anticoagulants
• Consider reversal agents for life-threatening bleeding
• Restart anticoagulation after 7 days when hemostasis is achieved 2

Antiplatelet Therapy

• Aspirin for secondary prevention should not be routinely stopped
• If stopped, restart as soon as hemostasis is achieved
• P2Y12 receptor antagonists should be reinstated within 5 days 2

Caveats and Pitfalls

1. Don't assume upper vs lower source: Up to 15% of patients presenting with suspected lower GI bleeding actually have an upper GI source. Consider upper endoscopy in cases of hemodynamic instability or if no lower source is identified. 2

2. Avoid delays in management: Prompt evaluation with appropriate imaging and endoscopy improves outcomes.

3. TXA use: While TXA has shown benefit in trauma, postpartum hemorrhage, and possibly upper GI bleeding, current evidence does not support its routine use in lower GI bleeding outside of clinical trials. 2, 1

4. Case-specific exceptions: In rare circumstances such as patients who refuse blood products (e.g., Jehovah's Witnesses) or patients on multiple antithrombotics with life-threatening bleeding, TXA might be considered as a temporizing measure, though evidence for this approach is limited to case reports. 5