Can tranexamic acid be used to stop an acute gastrointestinal bleed in an adult with new‑onset GI bleeding and no contraindications?

Can TXA Stop a GI Bleed?

Tranexamic acid (TXA) can reduce mortality and continued bleeding in upper gastrointestinal bleeding, but it is not included in current major guidelines for nonvariceal UGIB management and shows no benefit for lower GI bleeding.

Evidence for Upper GI Bleeding

Mortality and Bleeding Reduction

• TXA significantly reduces all-cause mortality by 40% (RR 0.60) in upper GI bleeding 1
• Continued bleeding rates are reduced by 40% (RR 0.60) compared to placebo 1
• Urgent endoscopic intervention requirements decrease by 65% (RR 0.35) 1
• An older meta-analysis showed similar mortality reduction (RR 0.61), though with less robust evidence 2

Practical Application

• Early IV administration (1g loading dose followed by 3g maintenance over 24 hours) may convert urgent endoscopy to elective procedures 3
• The time to endoscopy can be extended safely when TXA is administered, with urgent endoscopy needed in only 10-14% of TXA patients versus 30% of placebo patients 3
• Both IV alone and IV plus topical (via nasogastric tube) administration show benefit 3

Critical Limitation: Guideline Absence

Despite research showing benefit, the 2019 International Consensus Group guidelines for nonvariceal UGIB management do not recommend TXA 4. The guidelines specifically state:

• Somatostatin and octreotide are not routinely recommended 4
• H2 receptor antagonists are not recommended 4
• TXA is notably absent from all pharmacologic management recommendations 4

This omission likely reflects that most included trials predated modern endoscopic techniques and proton pump inhibitor (PPI) therapy—only one trial in the 2008 meta-analysis included these standard treatments 2.

Evidence for Lower GI Bleeding

TXA does NOT work for lower GI bleeding 5. A 2024 randomized controlled trial showed:

• No difference in transfusion requirements (p=0.89) 5
• No difference in number of packed red blood cell units needed (p=0.98) 5
• This represents the most recent high-quality evidence specifically addressing lower GI bleeding 5

Safety Considerations

• Thromboembolic events were not significantly increased in available trials 2
• No thromboembolic events documented during 1-week follow-up in one RCT 3
• However, adverse events were generally poorly reported across studies 2

Clinical Algorithm

For Upper GI Bleeding:

1. Initiate standard care per guidelines: IV PPI therapy, early endoscopy within 24 hours 4
2. Consider TXA (1g IV loading, then 3g over 24h) as adjunctive therapy in resource-limited settings or when endoscopy is delayed 1, 3
3. TXA should not replace endoscopic therapy, which remains the definitive treatment for high-risk stigmata 4

For Lower GI Bleeding:

• Do not use TXA—no evidence of benefit 5

Important Caveats

• The mortality benefit seen in meta-analyses comes primarily from older trials (pre-2008) that lacked modern endoscopic hemostasis and high-dose PPI protocols 2
• The 2024 ACR Appropriateness Criteria for UGIB imaging make no mention of TXA, focusing instead on endoscopy and angiography 4
• The evidence-practice gap exists: research suggests benefit, but guidelines have not incorporated TXA into standard protocols 4, 1