From the Guidelines
Tranexamic acid (TXA) is not recommended for gastrointestinal bleeding related to cholangiocarcinoma due to the lack of evidence supporting its benefit and potential increased risk of thromboembolic events. The use of TXA in acute gastrointestinal bleeding has been evaluated in several studies, but the evidence is limited and inconclusive 1. A recent study found no beneficial effect of TXA in patients with acute upper gastrointestinal bleeding, including those with suspected variceal bleeding and liver disease comorbidity 1. In fact, the study found an increased risk of venous thromboembolic events in patients receiving TXA, particularly those with comorbid liver disease or suspected variceal bleeding.
The management of gastrointestinal bleeding related to cholangiocarcinoma should focus on stabilizing the patient with fluid resuscitation, blood transfusions, and correction of any coagulopathy. The procedure of choice for managing bleeding is transarterial embolization (TAE), which involves identifying the bleeding vessel through angiography and selectively embolizing it using materials such as gelfoam, coils, or polyvinyl alcohol particles. TAE is effective because it provides targeted treatment directly to the bleeding site while being less invasive than surgery, which is particularly beneficial for cholangiocarcinoma patients who may have compromised liver function or advanced disease.
Some key points to consider when managing gastrointestinal bleeding related to cholangiocarcinoma include:
- Stabilizing the patient with fluid resuscitation and blood transfusions if necessary
- Correcting any coagulopathy with fresh frozen plasma or vitamin K
- Using TAE as the primary treatment for bleeding
- Monitoring for rebleeding and assessing for post-embolization syndrome
- Considering alternative approaches such as endoscopic intervention or surgery if TAE fails to control bleeding
It is essential to prioritize the patient's morbidity, mortality, and quality of life when making treatment decisions, and to base those decisions on the most recent and highest-quality evidence available 1. In this case, the evidence suggests that TXA is not a recommended treatment for gastrointestinal bleeding related to cholangiocarcinoma.
From the Research
Endoscopic Management of GI Bleeding Related to Cholangiocarcinoma
- The management of gastrointestinal (GI) tumor-related bleeding, including that from cholangiocarcinoma, is challenging due to high rebleeding rates and poor tissue response to endoscopic therapies 2.
- Endoscopic treatment may help reduce transfusion requirements, avoid surgery, and provide a temporary bridge to oncologic therapy 2.
- Various endoscopic techniques can be used in managing tumor bleeding, including thermal or mechanical therapy with injection therapy and newer topical agents 2.
Diagnostic Approach to Cholangiocarcinoma
- Cholangiocarcinomas are associated with poor overall survival, and the majority of tumors are unresectable at the time of diagnosis 3.
- Early diagnosis at a resectable stage is essential for improved outcomes, and endoscopic diagnosis is needed in the majority of patients with cholangiocarcinoma 3.
- Advanced imaging, endoscopic methods, and molecular markers can be used in the diagnostic approach to cholangiocarcinoma 4.
Treatment Options for Cholangiocarcinoma
- The sole curative treatment for cholangiocarcinoma is surgery, but 40-85% of all patients have recurrent disease even after radical excision 5.
- For unresectable cholangiocarcinoma without distant metastases, liver transplantation can yield promising survival rates 5.
- Chemotherapy with gemcitabine and cisplatin is considered the standard for palliative care 5.
- Target therapies and immune checkpoints inhibitors have been proposed as second- or third-line treatment, alone or in combination with chemotherapy or target therapies 6.