Can tranexamic acid (TXA) stop an upper gastrointestinal (GI) bleed due to varices?

Tranexamic Acid is Not Recommended for Upper GI Bleeding from Varices

Tranexamic acid (TXA) should not be used to stop upper gastrointestinal bleeding due to varices. 1 The evidence clearly shows that TXA is ineffective for variceal bleeding and may increase thrombotic complications in these patients.

Standard Management of Variceal Bleeding

The current standard of care for variceal bleeding includes:

1. Initial Resuscitation and Medical Management:

   • Restrictive blood transfusion strategy (target hemoglobin 7-9 g/dL) 1
   • Prompt initiation of vasoactive drugs (before endoscopy) 1
   • Antibiotic prophylaxis 1

2. Vasoactive Medications:

   • Octreotide: 50 μg IV bolus, followed by continuous infusion at 50 μg/h for 2-5 days 1
   • Somatostatin: 250 μg IV bolus, followed by continuous infusion at 250-500 μg/h for 2-5 days 1
   • Terlipressin (where available): 2 mg IV every 4 hours initially, then 1 mg IV every 4 hours for 2-5 days 1

3. Endoscopic Therapy:

   • For esophageal varices and GOV1 (gastroesophageal varices type 1): Endoscopic variceal ligation (EVL) is first-line 1
   • For gastric varices (GOV2 or IGV1): Endoscopic variceal obturation (EVO) with cyanoacrylate glue is preferred 1

4. Rescue Therapies (if bleeding cannot be controlled):

   • Balloon tamponade (temporary measure) 1
   • TIPS (transjugular intrahepatic portosystemic shunt) 1
   • Balloon-occluded retrograde transvenous obliteration (BRTO) for gastric varices with gastrorenal shunts 1

Evidence Against Tranexamic Acid in Variceal Bleeding

The 2022 European Association for the Study of the Liver (EASL) guidelines explicitly state: "In patients with cirrhosis and active variceal bleeding, tranexamic acid should not be used" (strong recommendation) 1.

This recommendation is based on a large randomized placebo-controlled trial that included over 12,000 patients with acute upper gastrointestinal bleeding, nearly half of whom had suspected variceal bleeding. Key findings include:

• No beneficial effect of TXA was observed in patients with suspected variceal bleeding 1
• A nearly 2-fold increase in venous thromboembolic events was observed in the TXA group 1
• The risk of venous thromboembolic events was concentrated in patients with liver disease/suspected variceal bleeding 1

The ineffectiveness of TXA in variceal bleeding is likely due to:

1. The limited role of hemostasis in variceal bleeding (which is primarily driven by portal hypertension)
2. The frequent occurrence of hypofibrinolytic state in critically ill patients with cirrhosis 1

Important Considerations

• Portal Pressure: Administration of blood products can increase portal pressure, potentially worsening bleeding outcomes 1
• Restrictive Transfusion: A restrictive red blood cell transfusion strategy (target hemoglobin 7-9 g/dL) improves outcomes 1
• Timing of Vasoactive Drugs: Vasoactive medications should be started as soon as variceal bleeding is suspected, preferably before endoscopy 1
• Duration of Therapy: Vasoactive drugs should be continued for 2-5 days after initial endoscopic hemostasis 1

Conclusion

For upper GI bleeding from varices, the focus should be on controlling portal hypertension with vasoactive drugs, performing appropriate endoscopic therapy, and considering rescue procedures like TIPS when needed. Tranexamic acid has no role in this setting and may increase thrombotic complications.