Advanced liver disease is associated with coagulopathy and bleeding that develops from several mechanisms. In common clinical practice, the bleeding is treated with blood products and/or pharmacologic agents based on their corrective effect on laboratory tests of hemostasis. We report the case of a 72-year-old man with end-stage liver disease with refractory bleeding in whom multiple therapeutic strategies failed, including massive blood product replacement, but who responded to the infusion of

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... tranexamic acid, an anti-fibrinolytic agent. The hyper-fibrinolytic state is difficult to diagnose with conventional clinical laboratory tests, but it was suspected in this patient with refractory bleeding and hypo-fibrinogenemia. Although largely used in the surgical setting, tranexamic acid may prove useful in medical settings characterized by bleeding and systemic fibrinolysis.