Article, Emergency Medicine

Topical use of tranexamic acid for the management of post-procedural rectal bleeding

a b s t r a c t

Tranexamic acid (TXA) is increasingly used in the Emergency Department (ED). While the intravenous form has been extensively studied and used, it’s utility in a topical formulation is not as widespread. Its reported use in the ED is mostly for control of epistaxis. We present a case of a 61 year old male with post-procedural Rectal bleeding, responsive to topical application of tranexamic acid. This case report demonstrates another novel application of TXA in emergency care.

(C) 2018

Case

A 61 year old male with a past medical history of hypertension, ele- vated prostate specific antigen, and atrial fibrillation maintained on as- pirin and metoprolol, was transferred to the ED from urology clinic after a trans-rectal prostate biopsy was complicated by post-procedural bleeding. The patient had undergone a prostate needle biopsy in clinic and was noted to have larger than expected bleeding per rectum post- procedurally, with an estimated blood loss of 100-200 mL. The rectum was packed with a gauze roll in order to control bleeding. Vitals in clinic were normal except for blood pressure elevated to a systolic of 150 mm Hg (diastolic not recorded). During transfer to ED by emer- gency medical services, the patient experienced a short syncopal episode.

In the ED, the patient was hypotensive to 98/53 mm Hg, was pale and in distress, but alert. He was noted to have rectal packing in place with apparent hemostasis. However, on examination of the anus and packing, several clots became apparent and bleeding continued.

Packing was replaced with a fresh gauze roll, however hemostasis was still not achieved.

Another gauze roll, soaked in 5 mL of injecTable 100 mg/mL TXA was then placed into the rectum to achieve hemostasis. Bleeding was noted to have ceased at re-evaluation five minute post gauze roll placement. The patient was re-evaluated at 30 minute intervals for the next 2 h

? There were no sources of support for this project, and this report has not been previously presented or published in anyway. There was no institutional review board approval obtained.

* Corresponding author at: Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston 02118, MA, USA.

E-mail address: [email protected] (Z. Altawil).

with no further bleeding noted. He was admitted for overnight observa- tion. The patient’s first hematocrit post-procedure was 44.1%, trending downwards to 38.1% over the course of the patient’s resuscitation. The decline was mirrored by decreases in both white blood cell count and platelet count (18,600/mcL to 14,000/mcL and 206,000/mcL to 185,000/mcL, respectively). During this time the patient received 3 L of normal saline boluses, suggesting a dilutional component to the de- cline. The patient was discharged the next day with no further bleeding noted, with a hematocrit of 34.1%.

Discussion

TXA, an antifibrinolytic derivative of lysine that competitively in- hibits the conversion of plasminogen to plasmin, has become increas- ingly more utilized in the ED. Intravenously, TXA has shown benefit in decreasing mortality among patients presenting with severe hemor- rhage [1] and emergency physicians are becoming familiar with its use in this capacity. Topically, it is extensively used in orthopedic sur- gery and has been shown to decrease peri-operative bleeding in cases of total hip/knee arthroplasty [2-4]. It use is also reported in dental/ oral bleeding [5], and post-partum hemorrhage [6]. In the ED, topical TXA has primarily been used for cases of epistaxis [7]. There is a newly emerging body of ED literature that has found successful use of TXA in trials for treatment of epistaxis [8,9] and urinary tract bleeding [10].

In this case report, we present a novel use of topical TXA for the con- trol of a post-procedural gastrointestinal bleed, refractory to conven- tional methods of Bleeding control. While topical use of TXA for cutaneous bleeds has been described prior in the literature [11], evi- dence for its use in rectal bleeding is sparse [12]. Rectal bleeding is the most common adverse event in transrectal prostate biopsy; however, severe bleeding is rare [13,14]. While conventional methods remain

https://doi.org/10.1016/j.ajem.2018.09.037

0735-6757/(C) 2018

the standard protocol for controlling post procedural bleeding, some studies have advocated for the prophylactic insertion of prophylactic hemostatic gelatin sponges to decrease the incidence of severe hemor- rhage [15]. Bleeding in this scenario is likely localized, and the availabil- ity of TXA in EDs and its low cost make it an ideal agent for this type of bleed.

The dosing used in this patient was similar to prior reports in the lit- erature for topical use [8]. Given the low risk of adverse events with top- ical TXA and limited available data, this case represents a possible use of TXA for the emergency management of a severe rectal bleed. TXA in its topical form seems to be a useful agent for Hemorrhage control when standard methods have failed. Further studies to examine the safety and efficacy of TXA in gastrointestinal bleeding are warranted.

References

  1. Williams-Johnson JA, McDonald AH, Strachan GG, Williams EW. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised, placebo- controlled trial. Lancet 2010;59(6):612-24. https://doi.org/10.1016/S0140-6736 (10)60835-5.
  2. Chen W-P. Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis. J Bone Joint Surg 2012. https://doi.org/10.2106/ JBJS.K.00873.
  3. Luo ZY, Wang HY, Wang D, Zhou K, Pei FX, Zhou ZK. Oral vs intravenous vs Topical tranexamic acid in primary hip arthroplasty: a prospective, randomized, double- blind, controlled study. J Arthroplast 2017;33(3):786-93. https://doi.org/10.1016/j. arth.2017.09.062.
  4. Lei Y, Xie J, Xu B, Xie X, Huang Q, Pei F. The efficacy and safety of multiple-dose in- travenous tranexamic acid on blood loss following total knee arthroplasty: a ran- domized controlled trial. Int Orthop 2017;41(10):2053-9. https://doi.org/10.1007/ s00264-017-3519-x.
  5. Zirk M, Zinser M, Buller J, et al. Supportive topical tranexamic acid application for he- mostasis in oral bleeding events – retrospective cohort study of 542 patients. J

    Cranio-Maxillofac Surg 2018;46(6):932-6. https://doi.org/10.1016/j.jcms.2018.03. 009.

    Kinugasa M, Tamai H, Miyake M, Shimizu T. Uterine balloon tamponade in combina- tion with topical administration of tranexamic acid for management of postpartum hemorrhage. Case Rep Obstet Gynecol 2015;2015:1-4. https://doi.org/10.1155/ 2015/195036.

  6. Birmingham AR, Mah ND, Ran R, Hansen M. Topical tranexamic acid for the treat- ment of Acute epistaxis in the emergency department. Am J Emerg Med 2018. https://doi.org/10.1016/j.ajem.2018.03.039.
  7. Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med 2013;31(9):1389-92. https://doi.org/ 10.1016/j.ajem.2013.06.043.
  8. Zahed R, Mousavi Jazayeri MH, Naderi A, Naderpour Z, Saeedi M. Topical tranexamic acid compared with anterior nasal packing for treatment of epistaxis in patients tak- ing antiplatelet drugs: randomized controlled trial. Acad Emerg Med 2018. https:// doi.org/10.1111/acem.13345.
  9. Moharamzadeh P, Ojaghihaghighi S, Amjadi M, Rahmani F, Farjamnia A. Effect of tranexamic acid on gross hematuria: a pilot randomized clinical trial study. Am J Emerg Med 2017. https://doi.org/10.1016/j.ajem.2017.09.012.
  10. Noble S, Chitnis J. Case report: use of topical tranexamic acid to stop localised bleed- ing. Emerg Med J 2013;30(6):509-10. https://doi.org/10.1136/emermed-2012- 201684.
  11. McElligott E, Quigley C, Hanks GW. Tranexamic acid and rectal bleeding. Lancet 1991;337(8738):431. https://doi.org/10.1016/0140-6736(91)91210-L.
  12. Brullet E, Guevara MC, Campo R, et al. Massive rectal bleeding following transrectal ultrasound-guided prostate biopsy. Endoscopy 2000;32(10):792-5. https://doi.org/ 10.1055/s-2000-7709.
  13. Djavan B, Waldert M, Zlotta A, et al. Safety and morbidity of first and repeat transrectal ultrasound guided prostate needle biopsies: results of a prospective European prostate cancer detection study. J Urol 2001;166(3):856-60. https://doi. org/10.1016/S0022-5347(05)65851-X.
  14. Kobatake K, Mita K, Kato M. Effect on hemostasis of an absorbable hemostatic gelatin sponge after transrectal prostate needle biopsy. Int Braz J Urol 2015;41(2):337-43. https://doi.org/10.1590/S1677-5538.IBJU.2015.02.22.

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