Can tranexamic acid (TXA) be used to stop an acute gastrointestinal bleed in an adult?

Can TXA Stop a GI Bleed?

No, tranexamic acid (TXA) should not be used to stop acute gastrointestinal bleeding—it provides no mortality or rebleeding benefit and increases the risk of dangerous blood clots.

Primary Evidence Against TXA Use

The highest-quality evidence comes from the HALT-IT trial (2020), which randomized nearly 12,000 patients with acute GI bleeding to high-dose TXA versus placebo. This landmark study found no reduction in death from bleeding (4% in both groups, RR 0.99,95% CI 0.82-1.18) and significantly increased venous thromboembolism risk (0.8% vs 0.4%, RR 1.85,95% CI 1.15-2.98). 1

Current Guideline Recommendations

Major gastroenterology societies explicitly recommend against TXA for GI bleeding:

• The American College of Gastroenterology recommends against high-dose IV TXA for gastrointestinal bleeding due to lack of benefit and increased thrombotic risk 2, 3
• The British Society of Gastroenterology states TXA use in acute lower GI bleeding should be confined to clinical trials only 2, 3, 4
• The European Association for the Study of the Liver provides a strong recommendation against TXA in patients with cirrhosis and active variceal bleeding 2, 3, 4

Why TXA Fails in GI Bleeding

The pathophysiology of GI bleeding differs fundamentally from trauma or surgical hemorrhage, where TXA has proven benefits. 3 In trauma, TXA works by preventing breakdown of clots at injury sites, but GI bleeding involves:

• Mucosal ulceration requiring endoscopic hemostasis, not fibrin stabilization 3
• Portal hypertension in variceal bleeding, where blood volume expansion from transfusion can paradoxically worsen bleeding 3
• A fragile hemostatic balance in cirrhosis that TXA disrupts, increasing thrombosis risk without stopping bleeding 3

The CRASH-2 trial showing mortality benefit in trauma should never be extrapolated to GI bleeding management. 5, 3

What to Do Instead

Standard evidence-based management should be prioritized:

• Resuscitation with restrictive transfusion strategy (target hemoglobin 7-9 g/dL in upper GI bleeding) 2, 3
• Early endoscopic intervention for diagnosis and definitive hemostatic therapy 3, 4
• High-dose proton pump inhibitor therapy (80 mg omeprazole bolus followed by 8 mg/hour infusion for 72 hours) following successful endoscopic therapy for ulcer bleeding 3
• For variceal bleeding: vasoactive drugs (octreotide/terlipressin), prophylactic antibiotics, and endoscopic band ligation—not TXA 2, 3
• 24/7 access to interventional radiology for embolization when endoscopic control fails 3

Critical Caveats and Pitfalls

Avoid these common mistakes:

• Do not use older meta-analyses published before 2021 that suggested TXA benefit—these included small, outdated trials conducted before modern endoscopic therapy and high-dose PPIs became standard 3
• Never extrapolate trauma data (CRASH-2) to GI bleeding—the underlying pathophysiology is completely different 5, 3
• Cirrhotic patients face particularly high thrombotic risk with TXA due to their already disrupted hemostatic balance 2, 3

The One Exception: Hereditary Hemorrhagic Telangiectasia

Oral TXA may be considered only for mild GI bleeding in HHT patients who maintain hemoglobin targets with oral iron supplementation, starting at 500 mg twice daily and titrating up to 1 g four times daily. 2, 3 This is based on low potential for harm in this specific population, not proven efficacy. Recent thrombotic events, atrial fibrillation, or known thrombophilia are contraindications. 3

Conflicting Older Research

A 2018 single-center trial (n=410) and a 2021 meta-analysis suggested TXA reduced urgent endoscopy rates and mortality. 6, 7 However, these findings are superseded by the much larger, higher-quality HALT-IT trial which had 30 times more patients and used modern methodology. 1 The older studies included historical trials with high bias risk conducted before current standard therapies existed. 3

Bottom Line for Clinical Practice

TXA has no role in routine management of acute GI bleeding. Focus on rapid resuscitation, early endoscopy, appropriate pharmacotherapy (PPIs for non-variceal, vasoactive drugs for variceal), and interventional radiology backup. The increased thrombotic risk without mortality benefit makes TXA use outside clinical trials unjustifiable. 2, 3, 4, 1