There has been very compelling literature suggesting TXA could be useful in the setting of an acute bleed.

The Cochrane Systematic Review and Meta-analysis, 2014 has been particularly promising

⇨7 randomized trials of TXA for UGIB, total of 1,654 total patients

⇨Saw a large reduction in mortality (pooled RR 0.61, 95% CI 0.42-0.89, p=.01)

⇨ No sig inc risk of thromboembolic events with tranexamic acid (pooled RR 1.86, 95% CI 0.6-5.24). No sig changes in re-bleeding or transfusions

STUDY #1 A randomized controlled trial of the effects of local tranexamic acid on mortality, rebleeding, and recurrent endoscopy need in patients with upper gastrointestinal hemorrhage.

 ⇨A single Center, double- blind, RCT in tertiary ED, 162 patients total

⇨INTERVENTION: a single dose of topical TXA (2g of 5% TXA in 100mL of isotonic saline solution vs control: 100mL isotonic saline via the nasogastric route

Primary outcome: No significant difference for mortality, re-bleeding, the need for endoscopic or surgical intervention or ED revisit rates between the groups

STUDY #2 HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial.

⇨An International, multi-center, randomized, placebo-controlled trial in 164 hospitals, 15 countries, 11,937 patients

⇨INTERVENTION: 1g TXA in 100ml NS loading dose given IV over 10 min, then 3g TXA in 1L NS infusion 24h vs. Control group: NS over 10 min, NS infusion

Primary Outcome: No significant difference in death due to bleeding within 5 days of randomization

Secondary Outcome: No significant differences in death due to bleeding in 24 hrs, within 28 days, all cause mortality at 28 days, interventions, transfusion, thromboembolic events, and many more

IN SUMMARY: There is no evidence to support the use of TXA in an acute GI Bleed! No evidence to suggest that it reduces mortality or decreases re-bleeding.

TXA may cause harm: it is associated with an increased risk of venous thromboembolic events in patients with GI bleeds (particularly in those with liver disease or mixed coagulation profile).

References: 

Bennett C, Klingenberg SL, Langholz E, Gluud LL. Tranexamic acid for upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2014;2014(11):CD006640. Published 2014 Nov 21. doi:10.1002/14651858.CD006640.pub3

Karadaş A, Doğan NÖ, Pinar SG, et al. A randomized controlled trial of the effects of local tranexamic acid on mortality, rebleeding, and recurrent endoscopy need in patients with upper gastrointestinal hemorrhage. Eur J Gastroenterol Hepatol. 2020;32(1):26-31. doi:10.1097/MEG.0000000000001555

HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020;395(10241):1927-1936. doi:10.1016/S0140-6736(20)30848-5