Hemorrhaging is also known as bleeding or abnormal bleeding as a result of blood loss due to internal.external leaking from blood vessels or through the skin.
I. Classifications of Hemorrhaging
According to the classification from the American College of Surgeons' Advanced Trauma Life Support (ATLS), Hemorrhaging is divided into 4 classes, depending to the volumes of blood loss and other factors
Classification of hemorrhage
| Class |
|
|
| Parameter | I | II | III | IV |
| Blood loss (ml) | <750 | 750–1500 | 1500–2000 | >2000 |
| Blood loss (%) | <15% | 15–30% | 30–40% | >40% |
| Pulse rate (beats/min) | <100 | >100 | >120 | >140 |
| Blood pressure | Normal | Decreased | Decreased | Decreased |
| Respiratory rate (breaths/min) | 14–20 | 20–30 | 30–40 | >35 |
| Urine output (ml/hour) | >30 | 20–30 | 5–15 | Negligible |
| CNS symptoms | Normal | Anxious | Confused | Lethargic |
Modified from Committee on Trauma. CNS = central nervous system(1a).
II. Types of hemorrhaging
A. Mouth
A.1. Hematemesis
Hematemesis is defined as a condition of either upper gastrointestinal tract fresh blood vomiting or altered blood vomiting due to acid on the blood.
1. Causes
There are many causes of Hematemesis, including
1.1. Mallory-Weiss syndrome:
There is records of 29 patients with
Mallory-Weiss
tears diagnosed by endoscopy. Ingestion of alcohol was a
chief cause of bleeding. Single tears were the largest in number and 68%
of the lacerations were seen just distal to the esophago-cardial
junction(1).
1.2. Irritation of the lining of the esophagus or stomach
Prolonged inflammation and allergic reaction or erosion as a result of irritant(s) can lead to damage to the cells of the lining of the esophagus or stomach.
1.3. Vomiting as a result of bleeding of the oral cavity, nose or throat
Vomiting of blood due to bleeding of the oral cavity, nose or throat
1.4. Vascular malfunctions
Vascular malformations, also known as
congenital vascular malformations
(CVMs) are defined as a condition of abnormalities in the formation of blood vessels of the gastrointestinal tract, including ulcer, bleeding due dilated submucosal veins in the stomach and intestines.
1.5. Tumors of the stomach or esophagus
Abnormal cell growth such as tumors of the stomach or esophagus can cause internal bleeding as a result of tumor causes of breaking off the blood veins and capillaries.
1.6. Acute and chronic radiation syndrome
a. Acute radiation syndrome is a defined as a condition of radiation poisoning as a result of the exposure to high amounts of ionizing radiation that affects gastrointestinal track. leading to infection and bleeding.
b. Chronic radiation syndrome
there is a report describes a 73-yr-old man who developed uncontrollable
hematemesis
due to a primary aortoduodenal fistula in the fourth portion of the
duodenum approximately 20 yr after radiotherapy and para-aortic lymph
node dissection for seminoma(2).
1.7. Influenza virus
There is a report of Seven children who presented during the
influenza A(H1N1) epidemic of 1988 are described. After a typical influenzal illness, they developed
haematemesis of varying severity. Endoscopy revealed haemorrhagic gastritis(3).
1.8.The viral haemorrhagic fevers
There are reviews of the viral
haemorrhagic fevers that infect man, namely smallpox, chikungunya
fever, dengue
fever, Rift Valley
fever, yellow
fever, Crimean
haemorrhagic fever, Kyasanur Forest disease, Omsk
haemorrhagic fever, Argentinian
haemorrhagic fever (Junin virus), Bolivian
haemorrhagic fever (Machupo virus), Lassa
fever,
haemorrhagic fever with renal syndrome, and Marburg and Ebola virus diseases(4).
1.9. Gastroenteritis
Gastroenteritis is defined as a condition of inflammation of the upper gastrointestinal track of that can lead to diarrhea, vomiting, and abdominal pain and cramping(5). In severe case, it can cause blood vomiting.
1.9. Gastritis
Gastritis is defined as a condition of an inflammation of the lining of the stomach as a result of excessive alcohol drinking and medication intake such as aspirin, ibuprofen, etc. over a prolonged period of time. there is a report of the case of 40-year-old woman who presented 6 weeks after intentional ingestion of hydrochloric acid with abdominal pain and
haematemesis. Gastroscopy showed a necrosed and ulcerated stomach with pyloric stricture(6).
1.10. Peptic ulcer
Dr. Thon K, and Dr.Röher HD.in the study of [
Hemorrhaging peptic ulcer--Therapy? When? Which?] indicated that a close correlation between the risk and incidence of recurrent bleeding
and the primary bleeding status during emergency endoscopy let us to
design a new concept of a more aggressive surgical strategy. The
dominating criteria for choice of treatment based on instant
endoscopical classification of bleeding type and activity(7).
1.11. Chronic liver disease
Chronic liver disease and its sequelae (often long-term results of
viral hepatitis) are commonplace.
Haematemesis
and hepatocellular failure are usually very difficult to manage due to a
lack of sophisticated support techniques in developing countries.
Invasive hepatic amoebiasis usually responds well to medical management;
however, spontaneous perforation can occur and the consequences of this
are serious(8).
1.12. Intestinal Schistosomiasis
Intestinal schistosomiasis, caused by the trematodes Schistosoma mansoni and S. japonicum, is found over a wide area of Africa, the Middle East, in the Orient, South America, and parts of the Caribbean. In the article of Progress report Intestinal schistosomiasis, showed that Intestinal Schistosomiasis can lead to liver diseases and Haematological Changes, as Patients suffering from intestinal schistosomiasis are frequently anaemic. In Puerto Rico Ramos-Morales14 found that 58 % of 1,547 untreated patients had a haemoglobin concentration of less than 13 g/100 ml with 4% less than 1Og/100 ml. Seventy-six per cent of these patients were aged 15 years or less and some had hookworm infection which could have contributed to blood loss(9).
1.13. History of Smoking
In a study of A total of 240 patients representing 18.7% of all patients (i.e. 1292)
who had fibreoptic upper GI endoscopy during the study period were
studied. Males outnumbered female by a ratio of 2.1:1. Their median age
was 37 years and most of patients (60.0%) were aged 40 years and below.
The vast majority of the patients (80.4%) presented with
haematemesis alone followed by malaena alone in 9.2% of cases. The use of non-steroidal anti-inflammatory drugs, alcohol and
smoking
prior to the onset of bleeding was recorded in 7.9%, 51.7% and 38.3% of
cases respectively. Previous history of peptic ulcer disease was
reported in 22(9.2%) patients. Nine (3.8%) patients were HIV positive.
The source of bleeding was accurately identified in 97.7% of patients(10).
1.14. Etc.
2. Symptoms
In the study of one hundred and seven consecutive patients with
hematemesis and/or melena and a
diagnosis
of duodenal, gastric, or esophageal ulcers were interviewed immediately
before or after endoscopy about the use of non-steroid
anti-inflammatory drugs (NSAIDs) and
symptoms before the hemorrhage, showed that if the patients admitted no
symptoms of
abdominal pain or discomfort, nausea, vomiting, or heartburn, they were classified as having no ulcer
symptoms before the hemorrhage. Patients who had not taken NSAIDs during the last 48 h before the
hemorrhage were classified as not having taken NSAIDs. Significantly
fewer patients had ulcer
symptoms in the group that had used NSAIDs than in the other group (p less than 0.01)(11).
2. Management and treatments
2.1. Severe blood blood and life threatening
In the study of treatment of
hematemesis and hematochezia in elderly patients by Department of Internal Medicine (III) Asahikawa Medical College,
hematemesis and
hematochezia (melena) in elderly patients are serious symptoms which
should be carefully handled since they can lead to death without
suitable
treatment. In elderly patients the advance of arteriosclerotic changes throughout
the body decreases blood flow and function in various organs. When these
arteriosclerotic changes become prominent in the gastric vascular
structure, bleeding from gastric ulcers tends to easily occur and it can
be difficult to stop. A large amount of bleeding can cause irreversible
shock due to the decreased cardiopulmonary function, and diminished
hepatorenal capacity would also be a decisive factor in determining the
outcome of the state of shock(11). In this case, Fluids and/or blood is administered, preferably by central venous
catheter, and the patient is prepared for emergency endoscopy, which is
typically done in theatres. Surgical opinion is usually sought in case the source of bleeding cannot be identified endoscopically, and laparotomy
is necessary. Securing the airway is a top priority in hematemesis
patients, especially those with a disturbed conscious level (hepatic
encephalopathy in oesophageal varices patient.) A cuffed endotracheal tube could be a life saving choice(12).
2.2. Blood loss but not life threatening
In this case, certain medication such as Proton-pump inhibitors (PPIs) to reduce gastric acid production and blood transfusion depending to levels of hemoglobin, no eating until endoscopy can be arranged.
Sources
(1a)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1065003/table/T1/
(1)
http://www.ncbi.nlm.nih.gov/pubmed/7222121
(2)
http://www.ncbi.nlm.nih.gov/pubmed/7611215
(3)
http://www.ncbi.nlm.nih.gov/pubmed/1988788
(4)
http://www.ncbi.nlm.nih.gov/pubmed/310725
(5)
http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=229
(6)
http://www.ncbi.nlm.nih.gov/pubmed/22140409
(7)
http://www.ncbi.nlm.nih.gov/pubmed/4058204
(8)
http://www.ncbi.nlm.nih.gov/pubmed/1764626
(9)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1411755/pdf/gut00657-0069.pdf
(10)
http://www.ncbi.nlm.nih.gov/pubmed/22537571
(11)
http://www.ncbi.nlm.nih.gov/pubmed/3879376
(12)
http://en.wikipedia.org/wiki/Hematemesis
A.2. Hemoptysis
Hemoptysis is defined as a condition of coughing up blood from the bronchi, larynx, trachea, or lungs.
1. Symptoms
Symptoms of Hemoptysis can be as a result of bronchial infection or a
sign of a more serious illness such as tumor and cancer
1.1 Chest pain
Chest pain us one of most common dymptoms of patient with Hemoptysism. It may be a result of the diseases have affected the nerve cells in the check area, including infection and tumor.
1.2. Dyspnea or shortness of breath (SOB)
This mau be the result of the disease has affected the lung in the absorption of oxygen, including tumor and infectiob There is a report of a 26-year-old Chinese man, presenting with
hemoptysis in the emergency room, was hospitalized because of dyspnea. The X-ray examination revealed a tumor in the right
chest cavity(1).
1.3. Fever
As a result of infection of the respiratory system.
1.4. Nausea and Vomiting
It is a result of bloods accumulation in the chest area needed to be cough out for the better function of the respiratory system.
1.5. Tachypnea (rapid breathing)
Top provide enough oxygen for the body
1.7. Etc.
2. Causes
2.1.
Cystic fibrosis (23%),
bronchiectasis (13%),
tuberculosis sequelae (8%),
chronic obstructive pulmonary disease (COPD)(6%)
According to the study of researchers at the Università degli Studi di Milano. Ospedale San Paolo, the causes of
haemoptysis
was as follows:
cystic fibrosis (23%),
bronchiectasis (13%),
tuberculosis sequelae (8%),
chronic obstructive pulmonary disease (COPD)
(6%) and
no apparent cause (21%). Major complications were recorded in
3/477 (0.6%): stroke (n=1), transient ischaemic attack (TIA) (n=1) and
transient quadriplegia (n=1). Minor complications were recorded in
143/477 (30%):
chest pain 86/143 (60%) and dysphagia 29/143 (20%). During a mean follow-up period of 14 (8-36) months,
haemoptysis recurrence was observed in 42/110 cases (38%) of cystic fibrosis and in 77/367 cases of other diseases (21%)(2).
2.2. Thrombasthenia is a rare disorder of blood platelets, which results in easy bruising and nosebleeds.
2.3.
Blood clot in the lung
Blood clot in the lung due to Venous thrombosis, as a result of blood clot formed in a vein breaks off and
transported to the right side of the heart into the lungs. must be coughed out for the normal function of the lung. There is a report of a young woman diagnosed as having microscopic
polyangiitis (MPO) presenting with diffuse alveolar hemorrhage (DAH).
DAH is a rare, but life-threatening disorder. The patients presented
with
dyspnea,
cough,
hemoptysis
(not constant). The radiographic features are very characteristic and
reveal the signs of diffuse, bilateral alveolar filling in chest HRCT
especially in middle and lower zones(3).
2.4. Bronchiectasis and Tuberculosis
There is a report of a 39-year-old woman presented with
chronic cough, haemoptysis
and hoarseness of voice. She had left recurrent laryngeal nerve palsy
and high inflammatory markers on investigation. CT thorax revealed
aortic wall thickening and traction
bronchiectasis. 2 D echocardiogram revealed grade 1 aortic regurgitation compatible with aortitis(4). Other researchers in the study of 154 patients admitted for life-threatening
hemoptysis (LTH) over 3 consecutive years. Bronchoscopy and
arteriography procedures were performed, as prescribed by the attending
physician. Patient evolution was followed 5 years post-event, wrote that teading causes of life-threatening
hemoptysis (LTH) were
bronchiectasis and tuberculosis. While bronchoscopy during a
hemoptysis
episode was effective in identifying the source of the bleeding, artery
embolization was more effective in stabilizing the patient both at the
short and long term(4a).
2.5. Pulmonary edema
Pulmonary edema has been reported in SCUBA divers, apnea divers, and long-distance swimmers. Researchers at the University Boulevard, in the study of Immersion
pulmonary edema in female triathletes, showed that Contributing factors include hemodynamic changes due to water immersion,
cold exposure, and exertion which elevate cardiac output, causing
pulmonary capillary stress failure, resulting in extravasation of fluid into the airspace of the lung(5).
2.6. Cystic fibrosis
Cystic fibrosis
(CF) is a recessive genetic disease characterized by dehydration of the
airway surface liquid and impaired mucociliary clearance and
Hemoptysis and pneumothorax are complications commonly reported in patients with
cystic fibrosis(6).
2. 7. Esophageal and Lung cancer
If the tumor in the lung and Esophagus cause the break off of the blood vessels, it can cause coughing of blood to protect the respiratory system.
2.8. Esophageal and/or laryngeal candidiasis
Esophageal and/or laryngeal candidiasis can cause signs and symptoms of
hemoptysis(7).
2.9. Pneumonia
There is a report of a 37-year-old man with
hemoptysis,
fever, and shortness of breath. The clinical and laboratory
examinations revealed that the patient had pseudohemoptysis due to S.
marcescens
pneumonia, on an immunocompromised pattern, because of the coexistence of sarcoidosis, accoring to the study by General Hospital, Aristotle University of Thessaloniki(8).
2.10. Others
In the study of
Hemoptysis: an uncommun case by Serviços de Medicina Interna e de Pneumologia, Hospital de Sousa Martin, researchers indicated that
hemoptysis is a
symptom that suggests a variety of pathologies that can be more or less
benign and even fatal, a life threatening for the person who suffers
it. Between the most common causes we have
bronchitis,
bronchiectasis and
bronchopulmonary neoplasia. Less frequent causes
are:
Goodpasture's syndrome,
Wegener's granulomatosis,
systemic lupus
erythematosus, between others(9).
3. Diagnosis
3.1. Bronchoscopy
Bronchoscopy is a diagnostic technique to visualize inside the airway with insertion of bronchoscope into the airways. In the study to evaluated the diagnostic accuracy of results from fiberoptic
bronchoscopy (FOB) and high-resolution computed tomography (HRCT) in 126
patients at Gangnam Severance Hospital (Seoul, Korea) who were suspected
of having pulmonary tuberculosis (PTB), found that FOB is a useful tool in the rapid diagnosis of active PTB with a high
sensitivity, specificity, PPV and NPV in sputum smear-negative
PTB-suspected patients. HRCT improves the sensitivity of FOB when used
in combination with FOB in sputum smear-negative patients suspected of
having PTB(10).
3.2. Laryngoscopy
Laryngoscopy
is a medical procedure to look at the back of the throat, including the voice box (larynx) and vocal cords.
3.3. Lung biopsy
Lung biopsy is the removal of a sample from the lung tissue
through the wall of your chest for examination.
3.4. Mediastinoscopy
Mediastinoscopy is a surgical examination of the inside of the upper chest between and in front of the lung,, if your doctor suspected that the Hemoptysis is caused by lung cancer.
3.5. Spirometry
Spirometry is test to measure the
pulmonary function, including the volume and flow of air that can be inhaled and exhaled.
3.6. Tonsillectomy
Tonsillectomy is a
surgical procedure to remove the tonsils from either side of the tonsillar fossa, if they are the cause of Hemoptysis.
3.7. Upper airway biopsy
It is a surgical removal of a sample from the upper airway
(nose, mouth, throat) for examination.
3.8. Etc.
3. Management
Researchers at the University of Wisconsin Medical School, Milwaukee, in the study of diagnosis and
management of Hemoptysis, indicated that patient's history should help determine the amount of blood and differentiate between
hemoptysis,
pseudohemoptysis, and hematemesis. A focused physical examination can
lead to the diagnosis in most cases. In children, lower respiratory
tract infection and foreign body aspiration are common causes. In
adults, bronchitis, bronchogenic carcinoma, and pneumonia are the major
causes. Chest radiographs often aid in diagnosis and assist in using two
complementary diagnostic procedures, fiberoptic bronchoscopy and
high-resolution computed tomography, which are useful in difficult cases
and when malignancy is suspected. The goals of
management are threefold: bleeding cessation, aspiration prevention, and treatment of the underlying cause. Mild
hemoptysis often is caused by an infection that can be managed on an outpatient basis with dose monitoring. If
hemoptysis persists, consulting with a pulmonologist should be considered. Patients with risk factors for malignancy or recurrent
hemoptysis also require further evaluation with fiberoptic bronchoscopy or high-resolution computed tomography(11). Other researchers suggested that the etiology of
hemoptysis is best categorized from the various system or site of bleeding. The management of
hemoptysis
begins with an initial assessment of gas exchange and hemodynamic
stability followed by an identification of the cause by means of
fiberoptic bronchoscopy, and chest imaging studies to attain cessation
of bleeding and to prevent future recurrence(12).
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(1)
http://www.ncbi.nlm.nih.gov/pubmed/22791000
(2)
http://www.nejm.org/doi/full/10.1056/NEJMcpc0708507
(3)
http://www.ncbi.nlm.nih.gov/pubmed/22335144
(4)
http://www.ncbi.nlm.nih.gov/pubmed/22905814
(4a)
http://www.ncbi.nlm.nih.gov/pubmed/22704276
(5)
http://www.ncbi.nlm.nih.gov/pubmed/21660230
(6)
http://www.ncbi.nlm.nih.gov/pubmed/20675678
(7)
http://www.ncbi.nlm.nih.gov/pubmed/7422428
(8)
http://www.ncbi.nlm.nih.gov/pubmed/21941452
(9)
http://www.ncbi.nlm.nih.gov/pubmed/18282444
(10)
http://www.ncbi.nlm.nih.gov/pubmed/22726571
(11)
http://www.ncbi.nlm.nih.gov/pubmed/16225028
(12)
http://www.ncbi.nlm.nih.gov/pubmed/20043609
B. Hematochezia (rectal bleeding)
Hematochezia is defined as a condition of the passage of bright red, bloody stool. In most cases it is an indication of hemorrhoids (swollen veins in and around the rectum) or diverticulitis, a
common digestive disease particularly found in the large intestine, as a result of infection or inflammation.
1. Symptoms
1.1. Abdominal cramping and distention
In the some case the passing of large amount of blood is accompanied with abdominal cramping and distention as a result of colitis (inflammation of the large intestine).
1.2. Constipation
It is a result of severe rectal pain.
1.3. Dizziness and Fatigue
These may be result of the influence of the blood loss causing not enough oxygen to be transported.
1.4. Fever
This can be a result of inflammation or infection of the large intestine.
1.5. Body weakness
It is a result of not enough blood to transport nutrients and oxygen to the cells and organ needed.
1.7. Fainting or sudden changes in the level of consciousness
This is an result due to large volume of blood loss and considered to be life threatening.
1.8. Etc.
2. Causes
2.1. Ectopic pregnancy
There is a report of case of severe
rectal bleeding due to an ectopic pregnancy in the wall of the cecum is reported. The usual preoperative studies for
rectal bleeding
were performed but did not yield a definitive diagnosis. At laparotomy
the right side of the uterus was found to be adherent to the cecum(1).
2.2. Abdominal colic and major gastrointestinal haemorrhage
There is a report of a case of massive
rectal bleeding resulting from the placental attachment of an
abdominal
pregnancy to the sigmoid colon is reported. Both mother and infant
survived this rare complication which should be considered when
abdominal colic and major gastrointestinal haemorrhage occur in a pregnant patient(2). Other researchers also report of a case of an unusual case of massive
bleeding per rectum caused by erosion into the caecum of placental tissue from an ectopic pregnancy is presented. Despite its rarity,
abdominal pregnancies may have to be considered in sexually active fertile women presenting with difficult torrential
bleeding from the lower gastrointestinal tract(3).
2.3. Angiodysplastic lesions (vascular lesions of the gastrointestinal tract)
In the study of a single angiodysplasias demonstrated by preoperative angiography in four patients and the review of the literature on intestinal
angiodysplastic lesions, found that the relative frequency of angiodysplasias in the right side of the colon
is noted. Visceral angiography is an important investigation in cases
where there is persistent or recurrent bleeding from the
gastrointestinal tract, especially when barium studies and laparatomy have been negative(4).
2.4. Coagulation disorder
In the study of
Rectal bleeding, deep venous thrombosis, and coagulopathy in a patient with Klippel-Trénaunay syndrome, reserachers indicated that this report validates the use of endorectal resection for venous
malformation of the rectum in patients with KTS and highlights the
difficult balance of controlling
bleeding by correction of a consumptive coagulopathy and the increased risk of thromboembolic complications(5).
2.5. Hemostatic disorders
In the report of a 79-year-old woman (weight, 69 kg) was hospitalized in a gastroenterology unit for severe
rectal bleeding.
She had been treated for 2 months with dabigatran etexilate 110 mg
twice daily for chronic atrial fibrillation. On admission, her
creatinine clearance (CrCl) was 20.7 mL/min/1.73 m(2), prothrombin time
(PT) less than 10% (reference range 70-130%), and international
normalized ratio (INR) 14.5 (venous
blood). Eleven days after admission, hematologic and renal function were normalized and
rectal bleeding stopped. An 84-year-old man (weight, 71 kg) was admitted for
rectal bleeding
with acute renal failure and dehydration that began while he was
treated with dabigatran etexilate 110 mg twice daily for atrial
fibrillation. On admission, CrCl was 33.5 mL/min/1.73 m(2), PT 13%, and
INR 7.53 (venous
blood).
Dabigatran etexilate was stopped on admission. At the end of the
hospitalization, CrCl was 66.5 mL/min/1.73 m(2), PT 54%, and INR 1.53.
In both cases, an objective causality assessment revealed that those
adverse reactions were probably related to dabigatran etexilate(6).
2.6. Colon cancer
It can be with or without pain. In the study of 604 patients and 22 (3.6%, 95% confidence interval [CI] = 2.0% to 5.2%) were diagnosed with colorectal
cancer. Significant predictors of colorectal
cancer
were found to be age (<50 years: odds ratio [OR] = 1; 50-69 years:
OR = 5.1, 95% CI = 1.4 to 18.6; > or = 70 years: OR = 8.2, 95% CI =
2.1 to 31.8) and blood mixed with the stool (Likelihood ratio [LR] 1.5;
adjusted OR = 3.8; 95% CI = 1.4 to 10.5). Presence of haemorrhoids
associated with bright red
bleeding not mixed with stool reduced the likelihood of
cancer (OR = 0.4, 95% CI = 0.1 to 1.2) but did not eliminate it--a
cancer was present in 2% of patients with these symptoms(7).
2.7. Colorectal polyps
In the conduction of two studies, the first in 1989, the second in 1991, in which we invited
Danish general practitioners to register 3-4 patients aged 40 and over
presenting with
rectal bleeding, researchers found that study 1 among 208 patients aged 40 and over and presenting with a first episode of
rectal bleeding,
colorectal cancer and
polyps were present in 15.4 and 7.7%, respectively. In Study 2 among 209 patients aged 40 and over and presenting with overt
rectal bleeding, 156 reported a first
bleeding episode or a change in their usual
bleeding pattern, and in this group
colorectal cancer and
polyps were diagnosed in 14.1 and 11.5%, respectively. In the group with unchanged
bleeding
the cancer polyp prevalence was 6.7% (P < 0.05). The patients in
both studies were followed through a yearly letter to the GP for at
least 32 and 22 months, respectively(8).
2.8. Hemorrhoids
There is a report of within a period of 18 months, 387 patients were referred to the
Proctologic Service at the Chaim Sheba Medical Center because of
recurrent
rectal bleeding.
Hemorrhoids
were found in 194 of these patients and further investigation showed
that 45 of the 194 patients (23.2%) had other coexisting colonic
pathology (12 cancers, 28 polyps, 4 inflammatory bowel diseases and 1
angiodysplasia). Sixteen of 40 patients with diverticulosis and 13 of 30
patients with hemoglobin less than 11 g/dl had additional colonic
pathology(9).
2.9. Etc.
3. Risk Factors
3.1. Aging
Risk of rectal bleeding increase with age as the result of weakened intestinal blood vessels. In the study of the group consisted of 102 patients (50 years of
age or less) with a flexible endoscope and an anoscopethat presented for evaluation of
rectal bleeding, showed that six patients had colitis; all but one of these patients were less than 40 years of
age. Flexible endoscopy and anoscopy provide complimentary information in middle-aged adults with
rectal bleeding(10)
3.2. Family history of gastrointestinal disease
People with the family of ulcerative colitis and Crohn’s disease, are at increased risk of rectal bleeding
3.3. Others, according to American Journal of Gastroenterology (1998)
93, 2179–2183; doi:10.1111/j.1572-0241.1998.00530.x
FROM: Self-reported rectal bleeding in a United States community: prevalence, risk factors, and health care seeking by Nicholas J Talley and Michael Jones(11)
Figure and tables index
| Any Rectal Bleeding | Blood Coating the Stools | Blood on Toilet Paper | Dark Blood Viewed in Stools |
|---|
| OR | 95% CI | OR | 95% CI | OR | 95% CI | OR | 95% CI |
|---|
Age  45 yr | 0.54*
| 0.41–0.72 | 1.19 | 0.67–2.12 | 1.64 | 0.43–6.23 | 0.60 | 0.29–1.23 |
| Sex (male) | 0.95 | 0.72–1.26 | 0.56 | 0.32–0.98 | 1.30 | 0.40–4.22 | 1.10 | 0.58–2.11 |
| Marital status | 0.82 | 0.55–1.22 | 3.0*
| 1.11–8.11 | 3.26 | 0.92–11.51 | 0.43 | 0.19–0.98 |
| Employment (yes vs no) | 0.55 | 0.31–0.96 | 0.59 | 0.16–2.18 | 0.55 | 0.06–4.72 | 1.67 | 0.50–5.63 |
| Education (< HS vs HS + tertiary) | 1.19 | 0.93–1.52 | 1.14 | 0.69–1.87 | 2.46 | 0.86–7.06 | 0.33 | 0.18–0.62 |
| Aspirin (none, some) | 1.08 | 0.82–1.42 | 1.06 | 0.61–1.84 | 1.52 | 0.47–4.94 | 0.75 | 0.39–1.44 |
| Ulcer history (yes) | 1.12 | 0.72–2.02 | 1.61 | 0.62–4.18 | 0.42 | 0.09–2.09 | 1.47 | 0.50–4.32 |
| Gastric surgery | 1.58 | 0.89–2.79 | 1.64 | 0.55–4.92 | 0.29 | 0.06–1.48 | 2.36 | 0.75–7.41 |
| IBS (yes) | 1.48*
| 1.04–2.10 | 1.06 | 0.54–2.05 | 1.07 | 0.28–4.15 | 1.65 | 0.78–3.50 |
| Constipation (yes) | 3.09*
| 2.33–4.10 | 1.51 | 0.86–2.67 | 0.24 | 0.05–1.14 | 2.30*
| 1.14–4.65 |
| Diarrhea (yes) | 2.08*
| 1.51–2.85 | 0.71 | 0.38–1.33 | 2.08 | 0.44–9.75 | 4.12*
| 2.10–8.11 |
| Urgency (yes) | 1.55*
| 1.11–2.15 | 1.24 | 0.66–2.35 | 0.94 | 0.25–3.60 | 3.25*
| 1.68–6.48 |
| Dyspepsia (yes) | 1.31 | 0.83–2.04 | 1.48 | 0.63–3.47 | 0.59 | 0.12–2.86 | 1.29 | 0.49–3.45 |
| Smoking (never vs current) | 0.96 | 0.67–1.39 | 0.41 | 0.18–0.97 | 0.74 | 0.18–3.09 | 3.67*
| 1.65–8.12 |
| Alcohol (0–6 vs 7 drinks wk) | 1.34 | 0.92–1.93 | 1.02 | 0.49–2.11 | 0.55 | 0.14–2.15 | 3.51 | 1.67–7.38 |
| Bowel surgery | 1.03 | 0.60–1.76 | 1.17 | 0.42–3.30 | 0.81 | 0.10–6.73 | 1.36 | 0.42–4.42 |
| Physician visits (bowel trouble) | 5.26*
| 3.19–8.65 | 1.17 | 0.53–2.57 | 0.82 | 0.17–3.93 | 2.93*
| 1.30–6.61 |
*
p < 0.05.
HS = high school; IBS = irritable bowel syndrome; CI = confidence interval; OR = odds ratio.
4. Diagnosis
4.1. Colonoscopy and arteriography
In the study of
Diagnosis and treatment of
hematochezia: guideline for clinical practice, DR. Wandono H. at the Department of Internal Medicine, Hajj Hospital Surabaya wrote that there are difficulties in clinical practice to find the cause and making the
diagnosis and therapy for
hematochezia.
Fortunately, the progress and development in medical technology,
especially colonoscopy and arteriography, has assisted in clinical
practice(12).
4.2. Blood test
The aim of blood test is to determine the hemoglobin concentration, coagulation and and
tests of liver and renal function are useful in checking for factors
that may exacerbate bleeding.
4.3. In stable patients
a. In younger patients
If the physical examination or anoscopy
reveals a bleeding hemorrhoid or other cause of local anal pathology, no other test is necessary as the possibility
of colon cancer is fewer than 1% in those
younger than age 30 years.
b. In older patients
80% of colorectal malignancies are found in patients older than
the age of 50 years. Even if a
local lesion such as a hemorrhoid is discovered. Twenty-seven percent of
patients with carcinoma of the rectum and 10% of those with carcinoma
of the sigmoid have been noted to have coincidental hemorrhoids. Most patients older than the age of 40 years with rectal
bleeding are candidates for colonoscopy.
4.2, 4.3,(13)
4.5. Computed tomography (CT) angiography
CT angiography is an accurate, cost-effective tool in the diagnosis of acute GI bleeding and can show the precise location of bleeding, thereby directing further management, according to the study by Shanghai Jiao Tong University School of Medicine(14).
4.6. Etc.
5. Treatment and management
5.1. Severe hematochezia
In the study to evaluate (a) the
diagnosis and treatment of 80 consecutive patients with severe, ongoing
hematochezia from unknown source and (b) the effectiveness and safety of urgent colonoscopy after oral purge, researcher wrote that because of ongoing severe
hematochezia in the intensive care unit, urgent
diagnosis
and treatment was recommended by the attending physicians and surgeons.
Emergency panendoscopy was performed before purge. Urgent
colonoscopy
was performed in the intensive care unit after patients received oral
purge and their gut was cleared of blood, clots, and stool. The final
diagnosis
in these patients was 74%
colonic lesions (30%
angiomata, 17%
diverticulosis, 11%
polyps or cancer, 9% focal ulcers, 7% other), 11%
upper
gastrointestinal
lesions, and 9% presumed small bowel lesions. No lesion site was
identified in 6%. Clinically significant fluid retention (medically
controlled) occurred in 4% of patients after purge. Sixty-four percent
of patients had intervention for control of bleeding: 39% had
therapeutic endoscopy, 24% surgery, and 1% therapeutic angiography. For
22 patients who also had emergency visceral angiography, the diagnostic
yield was 14% and the complication rate was 9%. and suggested that (a) Oral purge was effective and
safe for cleansing the colon of stool, clots, and blood. Sulfate purge
appeared to be safer than saline purge. (b) Before urgent colonoscopy
and purge, emergency panendoscopy was indicated to exclude an upper
gastrointestinal
bleeding source. (c) Urgent colonoscopy after purge was effective,
safe, and often diagnostic. (d) Compared with urgent colonoscopy, urgent
visceral angiography was often nondiagnostic. However, the examinations
may be complementary. (e) Hemostasis via colonoscopy has a definitive
role in the treatment of some focal colonic lesions such as bleeding
angiomata(15).
5.2. In Stable patients
In the study of to examine 58 patients, presenting with clinical signs of lower GI
hemorrhage, through a 24-month period. Preliminary endoscopy was
either negative or unfeasible. Images were obtained with a four-detector
row CT with an arterial (4 x 1 mm collimation, 0.8 mm increment, 1.25
mm slice width, 120 kV, 165 mAs) and portal venous series (4 x 2,5 mm
collimation, 2 mm increment, 3 mm slice width, 120 kV, 165 mAs). Time
interval between endoscopy and CT varied between 30 minutes and 3 hours.
The results of the
multi-phase Multi-Slice-Computertomography (MSCT) were correlated with clinical course and
surgical or endoscopical treatment(16).
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(1)
http://www.ncbi.nlm.nih.gov/pubmed/309659
(2)
http://www.ncbi.nlm.nih.gov/pubmed/3875846
(3)
http://www.ncbi.nlm.nih.gov/pubmed/1295424
(4)
http://www.ncbi.nlm.nih.gov/pubmed/4544790
(5)
http://www.ncbi.nlm.nih.gov/pubmed/22424361
(6)
http://www.ncbi.nlm.nih.gov/pubmed/22669799
(7)
http://www.ncbi.nlm.nih.gov/pubmed/17007706
(8)
http://www.ncbi.nlm.nih.gov/pubmed/8732328
(9)
http://www.ncbi.nlm.nih.gov/pubmed/3872288
(10)
http://www.ncbi.nlm.nih.gov/pubmed/7628276
(11)
http://www.nature.com/ajg/journal/v93/n11/fig_tab/ajg1998500t1.html#figure-title
(12)
http://www.ncbi.nlm.nih.gov/pubmed/18046067
(13)
http://www.dermaamin.com/site/images/stories/fruit/Primarycaremedicine/sid436397.html
(14)
http://www.ncbi.nlm.nih.gov/pubmed/20712058
(15) http://www.ncbi.nlm.nih.gov/pubmed/3263294
(16)
http://www.ncbi.nlm.nih.gov/pubmed/16333787
C.
Hematuria
Hematuria is defined as a medical condition with the presence of blood in the urine.
C.1 Causes and Risk factors
C.1. Causes
1. According to to the study at the University of Texas Southwestern Medical Center at Dallas,
bladder cancer based on > or =
10 years of smoking or environmental exposure with microscopic
hematuria
are rarely evaluated thoroughly and only 12.8% were referred for
urologic evaluation. Further studies are needed to evaluate both the
utilization and effectiveness of guidelines for
hematuria(1).
2. Kidney cancer
Tumor compresses onto capillary ot blood vessel can cause blood in the urine.
3. Inflammation
In the study of 82 of 1209 patients (6.8%), follow-up evaluation was
available for 43 of 85 (50.6%) findings by histologic diagnosis (n = 9),
imaging evaluation (n = 31), or clinical information (n = 3). There
were 11 (0.9%) examinations with acute findings, of which acute
inflammation
of the gastrointestinal tract and pancreaticobiliary system were the
most common. Seventy-two (5.9%) examinations revealed 74 nonacute but
important findings(2).
4. Sickle cell disease
There is a report of a case of recurrent gross
hematuria,
sickle cell trait and von Willebrand's
disease is reported. The gross
hematuria abated promptly after the institution of cryoprecipitate therapy(3).
5. Oral anticoagulation (OA)
Oral anticoagulation (OA) is a common treatment with a
known risk of fatal or major bleeding, but also minor bleeding symptoms
and menorrhagia can cause substantial discomfort and necessitate medical
or surgical interventions(4).
6. Vigorous exercise
There is a report of during a 6-month Amphibious Task Force deployment to the Mediterranean
Sea, five sailors and Marines were admitted to the ship's ward with
severe upper extremity pain, elevated serum muscle enzymes, and a
urinalysis dip positive for blood in the absence of microscopic
hematuria-a finding highly suggestive of myoglobinuria(5).
7. Sexual activity
In the study to assess the relationship between
sexual behaviour, urinary symptoms, urinalysis and bacteriuria in men attending STD clinics of 704 patients had had
sexual
intercourse (SI) within 14 days of testing, 424 had urinary symptoms
and 122 had pyuria. All 13 patients with positive culture had SI < 14
days before testing, urinary symptoms and pyuria. No association was
found between
sexual orientation, type of SI, number of
sexual partners, condom usage and bacteriuria(6).
8. Hemorrhagic cystitis
In the study to evaluate the association between the prevalence of
viral infections and hemorrhagic cystitis in pretransplant and posttransplant recipients and donors, showed that detection of single and multiple infections of BK
virus,
adenovirus, and cytomegalovirus in blood and/or urine samples of
hematopoietic stem cell transplant recipients, in combination with 1 or
more inducing factors of hemorrhagic cystitis were enforced on the
important role these risk factors play in the cause of hemorrhagic
cystitis(7).
9. Etc.
C.2. Risk factors
1. Family history
PKD1 gene abnormality is responsible for 85% of cases of ADPKD, patients
with PKD2 mutations typically present later and progress more slowly.
Patients with ADPKD can present with a positive
family history, hypertension, flank pain,
haematuria, renal insufficiency or proteinuria(8).
2. Other risk factors
In the study to determine the prevalence of urological pathology in a retrospective and
prospective study of patients with microscopic haematuria attending a
haematuria clinic, between January 1998 and May 2001, 781 patients attended the haematuria
clinic; of these, 368 (47%; median age 60 years, range 18-90) had a
history of microscopic haematuria, as detected by urine dipstick testing, showed that Urine cytology showed no malignant cells in any patient with a history
of microscopic haematuria. In 143 patients (39%), urine cytology showed
no red blood cells and all other investigations were normal. Of the
remaining 225 patients, IVU showed a
tumour in one (bladder),
renal
stones in 15 and an
enlarged prostate in two. Renal ultrasonography detected no additional pathology. Urine analysis showed one
urinary tract
infection. Flexible cystoscopy detected five patients with a bladder
tumour (all G1pTa), two urethral strictures,
five bladder stones and
enlarged prostates, six
enlarged
prostates only, and nine
red patches in the bladder, showing one
patient with
carcinoma in situ. No PSA levels were suggestive of
prostate cancer(9).
3. Etc.
C.2. Symptoms and signs
1. There is a report of healthy 60-year-old man presented with urinary urgency and microhematuria, The workup revealed no urothelial lesions, but did suggest a calcified
intraperitoneal mass causing extrinsic compression of the bladder.
Laparoscopic exploration revealed a glistening, spherical mass attached
by a stalk to the sigmoid colon. Removal and histologic examination of
the mass revealed calcified fat necrosis, most likely due to the
spontaneous torsion and calcification of an appendix epiploicae(10).
2. Blood clots
Massive
hematuria of renal origin was diagnosed in 4 dogs. In all dogs,
blood and
blood clots were clearly visible in the urine, according to study by Stone EA and researcher team(11).
3. Burning sensation
It may be result of inflammation or infection of the urinary track.
4. Pain when urinating (dysuria)
Telephone and clinic interviews identified 21 patients (36%) with symptoms of the
dysuria and
hematuria syndrome. The most common symptoms were
hematuria (71%) and bladder or suprapubic pain (76%). Of the patients 18 (86%)
ranked the severity of symptoms as mild to moderate and 3 (14%) ranked
them as severe, according to the study by the University of Washington(12).
5. Fever
As a result of infection or inflammation
6. Weight loss and flank pain
There is a report of 37-year-old man with a history of bladder augmentation presented with gross hematuria,
weight loss and flank pain, according to thye study of Department of Clinical Urology, University of Southern California Keck School of Medicine
7. Etc.
C.3. Diagnosis(13)
In the review of 1502 study participants, routine urinalysis was performed in 73.2% and 164 (14.9%) subjects had documented
hematuria
(>3 red blood cells / high-power field) before inclusion, found that
42.1% had no further evaluation. Additional testing included
1. Repeat
urinalysis (36%),
The aim of urtnalysis, including physical, chemical, and microscopic examinations, is to diagnose of urologic conditions such as calculi, urinary tract infection (UTI), and malignancy(14).
2. Urine culture (15.2%)
The mid stream urinary test to check for bacteria and germs in the urine. the aim is to test for urinary track infection.
3. Cytology (10.4%)
The aim of the test is to detect the irregular cells growth in the urinary track.
4. Imaging
(22.6% overall
The aim of the test is to evaluate the urinary tract including the kidneys, ureters, bladder, prostate, or urethra.
4.1.15.9% Computed tomography
The best choice to evaluate the kidneys and ureters.
4.2. 4.3% intravenous pyelography
Similar in analyzing the kidneys and ureters
4.3. 2.4% magnetic resonance imaging, and
Similar in analyzing the kidneys and ureters
4.4. Cystoscopy (12.8%).
The best choice to examine the bladder with the use of a thin, flexible cystoscope which is insert in to the bladder via the urethra
C.4. Treatment
Treatments are depending to the diagnosis of the diseases, including
1. Kidney stones
If the diagnosis found that Hematuria is the result of kidney stone, under normal condition, you are asked to drink plenty water to washout the stone and take pain control medicine. In some conditions, extracorporeal shock wave lithotripsy may be necessary to crush the stones to smaller piece to allow them to pass through via the urinary track. Other case, if the stone is found in the ureter, cystoscopy may help to it.
2. Urinary tract infection:
Urinary track infection is the result of invasion of bacteria, antibiotics will be taken over a certain period depending to types of bacteria.
3. Benign prostate enlargement
In case of
hematuria is caused by benign prostate enlargement then alpha blockers and 5α-reductase inhibitors may be taken.
4. Medications: If a medication is the causes of hematuria, then the medication may be replaced with other with the same effectiveness but with no side effect of urinary bleeding, if one can be found. If not, you doctor may weight the benefits and risk of the medicine.
5. Urinary tract blockage: if the disease is caused by a blockage, the surgery may be become necessary generally to correct or remove the block.
6. Etc.
Sources
(1)
http://www.ncbi.nlm.nih.gov/pubmed/20564400
(2)
http://www.ncbi.nlm.nih.gov/pubmed/22915402
(3)
http://www.ncbi.nlm.nih.gov/pubmed/313457
(4)
http://www.ncbi.nlm.nih.gov/pubmed/17260163
(5)
http://www.ncbi.nlm.nih.gov/pubmed/7816216
(6)
http://www.ncbi.nlm.nih.gov/pubmed/8976831
(7)
http://www.ncbi.nlm.nih.gov/pubmed/22142049
(8)
http://www.ncbi.nlm.nih.gov/pubmed/22497104
(9)
http://www.ncbi.nlm.nih.gov/pubmed/12175388
(10)
http://www.ncbi.nlm.nih.gov/pubmed/11880093
(11)
http://www.ncbi.nlm.nih.gov/pubmed/6629996
(12)
http://www.ncbi.nlm.nih.gov/pubmed/8326629
(13)
http://www.ncbi.nlm.nih.gov/pubmed/20564400
(14)
http://www.aafp.org/afp/2005/0315/p1153.html
D. Upper head hemorrhaging
D.1. Intracranial hemorrhage
Intracranial hemorrhage is defined as condition of bleeding within the skull.
D.1.1. Types of Intracranial hemorrhage
In the study to evaluate the sensitivity and specificity of head ultrasound (HUS) in the detection of intracranial
hemorrhage in premature neonates compared with brain MRI using susceptibility-weighted imaging (SWI), showed that Ultrasound (US) and MRI scans of the brain using SWI in premature
neonates were retrospectively evaluated for grade I-III germinal matrix
hemorrhage (GMH), periventricular hemorrhagic infarction (PVHI),
intra-axial hemorrhage other than PVHI,
extra-axial hemorrhage in each cerebral hemisphere and cerebellar
hemorrhage in each cerebellar hemisphere(1).
1. Intra-axial hemorrhage (cerebral hemorrhage)
Intra-axial hemorrhage is defined as a condition of bleeding in the brain itself, including bleeding of the brain tissues and ventricles,
2. Extra-axial hemorrhage
Extra-axial hemorrhage is defined as a condition of skull bleeding outside of the brain
D.1.2. Causes and Rick factors
1. Causes
a. Malignant melanoma
There is a report of a41-year-old female presented with repeated pontine
hemorrhage. Histological examination showed malignant melanoma cells. No cutaneous
lesion was found and positron emission tomography found no
abnormalities. Our presumptive diagnosis was primary
intra-axial brainstem malignant melanoma. The possibility of malignant melanoma should be considered in patients with
intra-axial brainstem lesion associated with repeated hemorrhages(2).
b. Head trauma
Patients receiving warfarin or clopidogrel are considered at increased risk for traumatic
intracranial hemorrhage after blunt
head trauma. In a study of a total of 1,064 patients were enrolled (768 warfarin patients [72.2%]
and 296 clopidogrel patients [27.8%]). There were 364 patients (34.2%)
from Level I or II
trauma
centers and 700 patients (65.8%) from community hospitals. One thousand
patients received a cranial CT scan in the ED. Both warfarin and
clopidogrel groups had similar demographic and clinical characteristics,
although concomitant aspirin use was more prevalent among patients
receiving clopidogrel. The prevalence of immediate traumatic
intracranial hemorrhage
was higher in patients receiving clopidogrel (33/276, 12.0%; 95%
confidence interval [CI] 8.4% to 16.4%) than patients receiving warfarin
(37/724, 5.1%; 95% CI 3.6% to 7.0%), relative risk 2.31 (95% CI 1.48 to
3.63). Delayed traumatic
intracranial hemorrhage
was identified in 4 of 687 (0.6%; 95% CI 0.2% to 1.5%) patients
receiving warfarin and 0 of 243 (0%; 95% CI 0% to 1.5%) patients
receiving clopidogrel(3).
c. High blood pressure
In a cohort of patients with spontaneous ICH, we obtained ICP values
from nursing documentation of hourly vital signs and reviewed charts to
rule out spurious ICP recordings, showed that among 243 patients, 57 (24 %) underwent ICP monitoring, of whom 40 (70 %; 95 % CI 57-82 %) had an episode of ICP > 20 mmHg.
Intracranial hypertension was less likely in older patients (OR per decade 0.6, 95 % CI 0.3-0.9) and after infratentorial
hemorrhage (OR 0.1, 95 % CI 0-0.7).
Intracranial hypertension
was not independently associated with mRS scores (OR 0.8, 95 % CI
0.3-2.3); this remained true for a threshold of >25 mmHg (OR 0.5,
95 % CI 0.2-1.5), number of elevations (OR 0.98 per elevation, 95 % CI
0.96-1.00), or area under the curve (OR 1.00 per mmHg × h, 95 % CI
0.99-1.01)(4).
d. Cerebral Aneurysms
Cerebral aneurysm is defined as a cerebrovascular disorder
causes of the blood vessel to bulge or balloon out of
the wall of a blood vessel as a result of the weaken
of blood vessels and veins and occurred mostly at the bifurcations and
branches of the large arteries located at the Circle of Willis. It can burst and cause bleeding into the brain(5) leading to Intracranial hemorrhage(5).
e. Brain Arteriovenous malformations
Brain Arteriovenous malformations is defined as a condition of
abnormal connection between veins and arteries, with a high rate of bleeding into the brain usually congenital.
f. Cerebral Amyloid angiopathy
Cerebral Amyloid angiopathy is defined as a condition of amyloid build up on the walls of the blood
vessel walls
in the brain. Cerebral amyloid angiopathy (CAA) is one of the main causes of intracerebral
hemorrhage (ICH), a subtypes of Intracranial hemorrhage in the elderly, according to the study by the Institut de Recerca, Universitat Autònoma de Barcelona(6).
g. Blood or bleeding disorders.
In the study to analyze the association of the initial platelet count with mortality and progression of
intracranial hemorrhage (ICH) in blunt traumatic brain injured (TBI) patients, showed that Of 626 TBI patients, 310 (49.5%) had a minimum of two brain computed
tomography scans and were able to have ICH progression evaluated.
Patients with
platelets
<175,000/mm3 had a significantly increased risk for ICH progression
(OR [95% CI]: 2.09 [1.07-4.37]; adjusted p = 0.043). ICH progression was
associated with increased need for craniotomy (OR [95% CI]: 3.27
[1.28-8.33]; adjusted p = 0.013) and mortality (OR [95% CI]: 3.41
[1.11-10.53]; adjusted p = 0.033). A platelet count <100,000/m3 was
an independent predictor for mortality (OR [95% CI]: 9.5 [1.3-71.4];
adjusted p = 0.029)(7).
h. Neurosarcoidosis
Neurosarcoidosis, a complication of sarcoidosis in which inflammation occurs in the nervous system
are related
intracranial haemorrhage, according to the study by the incorporating the National Children's Hospital, Trinity College(8).
g. Liver disease
Intracranial hemorrhages and late hemorrhagic
disease associated cholestatic
liver disease, according to the study of 11 infants with cholestatic
liver disease with different etiologies exhibiting
intracranial hemorrhage
(ICH) to researchers at the Erciyes University, Erciyesevler Mahallesi(9).
h. Brain tumors
There is a report of three cases of metastatic
brain tumors
which began with the symptoms of vascular accident and were
demonstrated as high density area by CT scan. Two of them are metastasis
of lung cancer and another, hepatoma. Characteristic CT findings are as
follow: 1) atypical location 2) non-homogeneous high density area
extending from the margin of the tumor (sometimes ring-like appearance)
3) surrounding massive edema 4) positive contrast enhancement 5)
multiple lesions(10).
i. Stroke and oral anticoagulants
Use of intravenous tissue-type plasminogen activator (IV tPA) for acute ischemic
stroke
is restricted to patients with an international normalized ratio (INR)
less than 1.7. However, a recent study showed increased risk of
symptomatic
intracranial hemorrhage after IV tPA use in patients with oral anticoagulants (OAC) even with an INR less than 1.7(11).
j. Etc.
2. Risk factors
1. According to the study of Risk factors for intracranial hemorrhage and nonhemorrhagic stroke after fibrinolytic therapy (from the GUSTO-i trial), showed that Of 592 patients in the Global Utilization of Streptokinase and tPA for
Occluded Arteries-I trial who had a stroke during initial
hospitalization, the risk for intracranial hemorrhage was significantly
greater in those with recent
facial or head trauma (odds ratio 13.0, 95%
confidence interval 3.4 to 85.5);
dementia was additionally associated
with an increased risk for intracranial hemorrhage (odds ratio 3.4, 95%
confidence interval 1.2 to 10.2). Because facial or head trauma may
greatly influence treatment decisions, this risk factor should be
incorporated into models designed to estimate the risks and benefits of
fibrinolytic therapy(12).
D.1.2. Symptoms
1. Intracranial pressure
Intracranial pressure as a result of a traumatic brain injuries can cause large mass which puts pressure on the brain(13).
2. Severe headache followed by vomiting is one of the more common symptoms of intracerebral hemorrhage, a sub types of Intracranial hemorrhage(14).
3.
Seizures with no previous history of seizures
In the study to determine the outcome and prognostic factors in those patients with severe AVM-ICH, showed that there were seven males and nine females with a mean age of 32 years
(range 6-66). All had Glasgow coma score 8 or less and most exhibited
motor posturing and/or dilated pupils. Fifteen patients had
intraprenchymal, ten had intraventricular, and four had subarachnoid
hemorrhage
(SAH). Twelve patients underwent hematoma evacuation with concomitant
decompressive craniectomy in 11 and external ventricular drainage (EVD)
in six. EVD was the only treatment offered to four patients. AVM
excision was not routinely attempted in the acute phase. Three patients
died from extensive bihemispheric infarction and refractory
intracranial
pressure. All 13 survivors improved neurologically and 12 had an
acceptable functional outcome (modified Rankin scale ≤ 4) after a mean
follow-up of 10 months (range 1-49). Among all clinical, radiological,
and operative variables, only cisternal SAH (P = 0.007) and early
seizures (P = 0.018) were significantly associated with death(15).
3.
Other symptoms as a result of central nervous system has been affect by intracranial hemorrhage, such as weakness in an arm or leg, decreased alertness, tingling or numbness, difficulty writing or reading, loss of motor tremors, loss of balance, etc.
D.1.3. Diagnosis
After a complete physical and history examination, the tests which your doctor may order include
1. Computed tomography (CT)
Computed tomography (CT)
is the standard diagnostic tool uses X-rays to make detailed pictures of structures inside the skull to check for fractures and bleeding, specially in case of trauma. Scheduled repeat head
computed tomography
after mild traumatic brain injury has been shown to have limited use
for predicting the need for an intervention. We hypothesized that repeat
computed tomography in persons with
intracranial hemorrhage
and a Glasgow Coma Scale (GCS) score of 13 to 15, without clinical
progression of neurologic symptoms, does not impact the need for
neurosurgical intervention or discharge GCS scores, according to the study by The University of Texas-Southwestern Medical Center(16).
2. Lumbar puncture
If the CT is negative for
bleeding, lumbar puncture or a spinal tap may be necessary to collect a sample of cerebrospinal fluid (CSF)
to check for the presence of blood. There is a report of two cases of
spinal epidural hematoma and two cases of
intracranial subdural hematoma after
lumbar puncture
(LP) are reported in children receiving chemotherapy for acute
lymphoblastic leukemia and non-Hodgkin lymphoma. The bleeding was
asymptomatic but interfered with treatment in one case, and caused
either severe backache or headache but no neurological deficit in the
other three patients(17).
3. Magnetic resonance imaging (MRI)
can be helpful in detecting structural abnormalities of the body to determine the extent of injury to the brain.
4. Arteriography
In case a
ruptured aneurysm is suspected, arteriography, a medical imaging technique used to visualize the inside, or lumen, of blood vessels to pinpoint the location of the
ruptured aneurysm.
5. Other tests may be necessary, depending to conditions of the patient and suspection of the doctor.
Some researchers suggested (in case of ttrauma and absence of trauma)
that ICH is diagnosed through history, physical examination, and, most
commonly, noncontrast CT examination of the brain, which discloses the
anatomic bleeding location. Trauma is a common cause. In the absence of
trauma, spontaneous intraparenchymal
hemorrhage
is a common cause associated with hypertension when found in the deep
locations such as the basal ganglia, pons, or caudate nucleus(18).
D.1.4. Treatments
Treatments of Intracranial hemorrhage are completely depending to diseases of differentiation
1. Medication
a. Antihypertensive therapy
In the study of the efficacy of the American Heart Association/American Stroke
Association guidelines for ultra-early, intentional antihypertensive
therapy in intracerebral
hemorrhage, showed that there are clinical benefits, by the prevention of subsequent HE, in
maintaining a MAP level lower than that recommended by the the American Heart Association/American Stroke Association (AHA/ASA) (110
mm Hg) after hospitalization for patients who have intracerebral
hemorrhage (ICH)(19).
b. Factor VII
Factor VII is a protein that causes blood to clot. Several studies have demonstrated successful correction of the
international normalized ratio (INR) using prothrombin complex
concentrate (PCC) or recombinant activated
factor VII (rFVIIa). To our knowledge, no study has directly compared these agents for treatment of warfarin-related ICH(20).
c. Mannitol and hypertonic saline
In the study to develop effective strategies for the medical treatment of ICP in cases of ICH, we evaluated the therapeutic efficacy of
mannitol and hypertonic saline in a canine model of ICH, found that
hypertonic saline, in both 3 and 23.4% concentrations, is as effective as
mannitol in the treatment of
intracranial
hypertension observed in association with ICH. Hypertonic saline may
have a longer duration of action, particularly when used in 3% solution.
None of three treatment regimens influence regional cerebral blood flow
or cerebral metabolism(21).
d. Acetaminophen to relieve the symptoms of headache and body temperature.
e. Corticosteroids
Corticosteroids, a synthetic drug and
closely resemble cortisol, which is produced by the adrenal glands may be used in case of hypertensives and swelling.
f. Etc.
2. Non medical treatments
a. In case of
intracranial pressure, placement of
intracranial pressure monitors (The intracranial pressure (ICP) is monitored and ICP also can be lowered by draining cerebral spinal fluid (CSF) out through the catheter) by non-neurosurgeons: Excellent outcomes can be achieved. Placement of ICP monitors may be performed safely by both neurosurgeons
and non-neurosurgeons. This procedure should thus be considered a core
skill for trauma surgeons and
surgical
residents alike, thereby allowing initiation of prompt medical
treatment in both rural areas and trauma centers with inadequate
neurosurgeon or fellow coverage, according to the study by Department of Trauma Services, Via Christi Hospital on Saint Francis (J.M.H.(22).
3. Surgery
"Currently, most neurosurgeons in the UK would operate on patients with a deteriorating conscious level and a worsening neurological deficit. In addition, haematomas between 20—80 ml in volume are more likely to be operated upon as are lobar/superficial haematomas. With cerebellar haemorrhage, although there are again no randomized controlled trials comparing surgical and conservative treatment, there seems to be greater agreement that hematomas greater than 3—4 cm should be operated upon, especially when there is concomitant clinical deterioration or hydrocephalus", according to the study of Surgical treatment of intracerebral haemorrhage by University of Newcastle upon Tyne, Newcastle upon Tyne, UK (23).
Sources
(1)
http://www.ncbi.nlm.nih.gov/pubmed/22633043
(2)
http://www.ncbi.nlm.nih.gov/pubmed/19029781
(3)
http://www.ncbi.nlm.nih.gov/pubmed/22626015
(4)
http://www.ncbi.nlm.nih.gov/pubmed/22833445
(5)
http://diseases-researches.blogspot.ca/p/cerebral-aneurysm.html
(6)
http://www.ncbi.nlm.nih.gov/pubmed/22261638
(7)
http://www.ncbi.nlm.nih.gov/pubmed/20386283
(8)
http://www.ncbi.nlm.nih.gov/pubmed/22681045
(9)
http://www.ncbi.nlm.nih.gov/pubmed/22327309
(10)
http://www.ncbi.nlm.nih.gov/pubmed/7279131
(11)
http://www.ncbi.nlm.nih.gov/pubmed/21980194
(12)
http://www.ajconline.org/article/S0002-9149%2803%2901581-9/abstract
(13)
http://emedicine.medscape.com/article/247664-overview
(14)
http://en.wikipedia.org/wiki/Cerebral_hemorrhage
(15)
http://www.ncbi.nlm.nih.gov/pubmed/21234617
(16)
http://www.ncbi.nlm.nih.gov/pubmed/22929497
(17)
http://www.ncbi.nlm.nih.gov/pubmed/16155928
(18)
http://www.ncbi.nlm.nih.gov/pubmed/22284061
(19)
http://www.ncbi.nlm.nih.gov/pubmed/20541417?dopt=Abstract
(20)
http://www.ncbi.nlm.nih.gov/pubmed/21492631
(21)
http://www.ncbi.nlm.nih.gov/pubmed/10232539
(22)
http://www.ncbi.nlm.nih.gov/pubmed/22929484
(23)
http://bmb.oxfordjournals.org/content/56/2/444.full.pdf
D.2. Cerebral hemorrhage
Cerebral hemorrhage, a sub type of intracranial hemorrhage, is defined as a condition of bleeding as a result of
artery bursts in the brain, considered as one of the main cause of stroke, according to the research article of Endoscopic management of hypertensive intraventricular haemorrhage with obstructive hydrocephalus(1).
D.2.1. Causes and Rick factors
1. Causes
a. Penetrating head trauma
Patients receiving warfarin or clopidogrel are considered at increased risk for traumatic
intracranial hemorrhage after blunt
head trauma. In a study of a total of 1,064 patients were enrolled (768 warfarin patients [72.2%]
and 296 clopidogrel patients [27.8%]). There were 364 patients (34.2%)
from Level I or II
trauma
centers and 700 patients (65.8%) from community hospitals. One thousand
patients received a cranial CT scan in the ED. Both warfarin and
clopidogrel groups had similar demographic and clinical characteristics,
although concomitant aspirin use was more prevalent among patients
receiving clopidogrel. The prevalence of immediate traumatic
intracranial hemorrhage
was higher in patients receiving clopidogrel (33/276, 12.0%; 95%
confidence interval [CI] 8.4% to 16.4%) than patients receiving warfarin
(37/724, 5.1%; 95% CI 3.6% to 7.0%), relative risk 2.31 (95% CI 1.48 to
3.63). Delayed traumatic
intracranial hemorrhage
was identified in 4 of 687 (0.6%; 95% CI 0.2% to 1.5%) patients
receiving warfarin and 0 of 243 (0%; 95% CI 0% to 1.5%) patients
receiving clopidogrel(2).
b. Amyloid angiopathy
In the review of neuropathologic studies suggestion of an association between
cerebral amyloid angiopathy (CAA) and small ischemic infarctions as well as hemorrhages by analyzing MR images from 78 subjects with a diagnosis of probable CAA
and a similar aged group of 55 subjects with Alzheimer disease or mild
cognitive impairment (AD/MCI) for comparison. DWI and apparent diffusion
coefficient (ADC) maps were inspected for acute or subacute infarcts, showed that MRI evidence of small subacute infarcts is present in a substantial proportion of living patients with advanced
cerebral amyloid angiopathy
(CAA). The presence of these lesions is associated with a higher burden
of hemorrhages, but not with conventional vascular risk factors(3).
c. Cerebral venous sinus thrombosis
Cerebral venous sinus thrombosis is defined as a rare condition
of stroke as a result from thrombosis (a blood clot) of the dural venous sinuses. There is a report of a A 65-year-old man presented with right hemiparesis and loss of consciousness.
Brain computed tomography showed a left frontoparietal
hemorrhage. Angiographic studies with magnetic resonance imaging showed the presence of a partial superior saggital
sinus thrombosis.
With a diagnosis of CVST, intravenous heparin was administered. After
24 hours the patient had a symptomatic increase in ICH size, and 2 days
later the patient developed a status epilepticus with new evidence of
rebleeding. Anticoagulant treatment was stopped and the patient
experienced neurological improvement, with no new episodes of rebleeding(4).
d. Infection of Streptococcus mutans
Infection with
Streptococcus mutans expressing collagen-binding protein (CBP) is a potential risk factor for haemorrhagic stroke(5).
e. Fetal cytomegalovirus infection
There is a report of a 38-year-old gravida 3, para 2 at 16 weeks of gestation who underwent
ultrasound examination for anomaly screening. The scan revealed an
extensive irregular echogenic area in the fetal brain, especially at the
level of lateral ventricles, suggestive of intraventricular and
cerebral hemorrhage due to intrauterine cytomegalovirus (CMV)
infection(6).
e.
Cerebral Aneurysms
Cerebral aneurysm is defined
as a cerebrovascular disorder
causes of the blood vessel to bulge or balloon out of
the wall of a blood vessel as a result of the weaken
of blood vessels and veins and occurred mostly at the bifurcations and
branches of the large arteries located at the Circle of Willis. It can
burst and cause bleeding into the brain(5) leading to Intracranial
hemorrhage(7)
f. Brain Arteriovenous malformations
Brain Arteriovenous malformations is defined as a condition of
abnormal connection between veins and arteries, with a high rate of bleeding into the brain usually congenital.
g. Etc.
2. Risk factors
In the study of a total of 1714 patients with hemorrhagic stroke
participation in the Hemorrhagic Stroke Project (HSP), showed that of these, 217 cases met the
criteria for primary ICH. Cases with primary ICH
were matched to 419 controls. Independent risk factors for ICH included
hypertension
(adjusted odds ratio [OR], 5.71; 95% CI, 3.61 to
9.05),
diabetes (adjusted OR, 2.40; 95% CI, 1.15 to 5.01), menopause
(adjusted
OR, 2.50; 95% CI, 1.06 to 5.88), current
cigarette smoking (adjusted OR, 1.58; 95% CI, 1.02 to 2.44),
alcoholic
drinks≥2/day
(adjusted OR, 2.23; 95% CI, 1.16 to 4.32),
caffeinated drinks≥5/day (adjusted OR, 1.73; 95% CI, 1.08 to 2.79), and
caffeine
in drugs (adjusted OR, 3.55; 95% CI, 1.24 to
10.20)(8).
D.2.2. Symptoms
1. Intracranial pressure
Intracranial pressure as a result of a traumatic brain injuries can cause large mass which puts pressure on the brain(9).
2. Severe headache followed by vomiting is one of the more common symptoms of intracerebral hemorrhage, a sub types of Intracranial hemorrhage(10).
3.
Seizures with no previous history of seizures
In the study to
determine the outcome and prognostic factors in those patients with
severe AVM-ICH, showed that there were seven males and nine females with
a mean age of 32 years
(range 6-66). All had Glasgow coma score 8 or less and most exhibited
motor posturing and/or dilated pupils. Fifteen patients had
intraprenchymal, ten had intraventricular, and four had subarachnoid
hemorrhage
(SAH). Twelve patients underwent hematoma evacuation with concomitant
decompressive craniectomy in 11 and external ventricular drainage (EVD)
in six. EVD was the only treatment offered to four patients. AVM
excision was not routinely attempted in the acute phase. Three patients
died from extensive bihemispheric infarction and refractory
intracranial
pressure. All 13 survivors improved neurologically and 12 had an
acceptable functional outcome (modified Rankin scale ≤ 4) after a mean
follow-up of 10 months (range 1-49). Among all clinical, radiological,
and operative variables, only cisternal SAH (P = 0.007) and early
seizures (P = 0.018) were significantly associated with death(11).
3.
Other symptoms
as a result of central nervous system has been affect by intracranial
hemorrhage, such as weakness in an arm or leg, decreased alertness,
tingling or numbness, difficulty writing or reading, loss of motor
tremors, loss of balance, etc.
D.2.3. Diagnosis
1.
Computed tomography (CT) scan
If your doctor suspects the bleeding is within the brain itself, then
CT scan is the best choice. Computed tomography (CT)
is the standard diagnostic tool uses
X-rays to make detailed pictures of structures inside the skull to
check for fractures and bleeding, specially in case of trauma. Scheduled repeat head
computed tomography
after mild traumatic brain injury has been shown to have limited use
for predicting the need for an intervention. We hypothesized that repeat
computed tomography in persons with
intracranial hemorrhage
and a Glasgow Coma Scale (GCS) score of 13 to 15, without clinical
progression of neurologic symptoms, does not impact the need for
neurosurgical intervention or discharge GCS scores, according to the
study by The University of Texas-Southwestern Medical Center(12).
2. A Lumbar puncture
If CT scan can not identify the diagnosis, your doctor may suggest a lumbar
puncture (spinal tap) to rule out subarachnoid
hemorrhage.
Lumbar puncture or a spinal tap may be necessary to collect a sample of cerebrospinal fluid (CSF)
to check for the presence of blood. There is a report of two cases of
spinal epidural hematoma and two cases of
intracranial subdural hematoma after
lumbar puncture
(LP) are reported in children receiving chemotherapy for acute
lymphoblastic leukemia and non-Hodgkin lymphoma. The bleeding was
asymptomatic but interfered with treatment in one case, and caused
either severe backache or headache but no neurological deficit in the
other three patients(13).
3. Other tests such as
a Magnetic resonance imaging (MRI)
can be helpful in detecting structural abnormalities of the body to determine the extent of injury to the brain.
b. Arteriography
In case a
ruptured aneurysm is suspected, arteriography, a medical imaging technique used to visualize the inside, or lumen, of blood vessels to pinpoint the location of the
ruptured aneurysm.
4. Etc.
D.2.4. Treatments
Depending on the underlying abnormality
1. Medication
a. Antihypertensive therapy
In the study of the efficacy of the American Heart Association/American Stroke
Association guidelines for ultra-early, intentional antihypertensive
therapy in intracerebral
hemorrhage, showed that there
are clinical benefits, by the prevention of subsequent HE, in
maintaining a MAP level lower than that recommended by the the American
Heart Association/American Stroke Association (AHA/ASA) (110
mm Hg) after hospitalization for patients who have intracerebral
hemorrhage (ICH)(14).
b. Factor VII
Factor VII is a protein that causes blood to clot. Several studies have demonstrated successful correction of the
international normalized ratio (INR) using prothrombin complex
concentrate (PCC) or recombinant activated
factor VII (rFVIIa). To our knowledge, no study has directly compared these agents for treatment of warfarin-related ICH(15).
c. Mannitol and hypertonic saline
In
the study to develop effective strategies for the medical treatment of
ICP in cases of ICH, we evaluated the therapeutic efficacy of
mannitol and hypertonic saline in a canine model of ICH, found that
hypertonic saline, in both 3 and 23.4% concentrations, is as effective as
mannitol in the treatment of
intracranial
hypertension observed in association with ICH. Hypertonic saline may
have a longer duration of action, particularly when used in 3% solution.
None of three treatment regimens influence regional cerebral blood flow
or cerebral metabolism(16).
d. Acetaminophen to relieve the symptoms of headache and body temperature.
e. Corticosteroids
Corticosteroids, a synthetic drug and
closely resemble cortisol, which is produced by the adrenal glands may be used in case of hypertensives and swelling.
f. Etc.
2. Non medical treatments
a. In case of
intracranial pressure, placement of
intracranial
pressure monitors (The intracranial pressure (ICP) is monitored and ICP
also can be lowered by draining cerebral spinal fluid (CSF) out through
the catheter) by non-neurosurgeons: Excellent outcomes can be
achieved. Placement of ICP monitors may be performed safely by both
neurosurgeons
and non-neurosurgeons. This procedure should thus be considered a core
skill for trauma surgeons and
surgical
residents alike, thereby allowing initiation of prompt medical
treatment in both rural areas and trauma centers with inadequate
neurosurgeon or fellow coverage, according to the study by Department of
Trauma Services, Via Christi Hospital on Saint Francis (J.M.H.(17).
3. Surgery
a. Non invasive treatment
Interventional radiology involves treatments that include passing a
catheter to widen or to close off blood vessels in the brain without
surgery(18).
b. Surgery
"Currently,
most neurosurgeons in the UK would operate on patients with a
deteriorating conscious level and a worsening neurological deficit. In
addition, haematomas between 20—80 ml in volume are more likely to be
operated upon as are lobar/superficial haematomas. With cerebellar
haemorrhage, although there are again no randomized controlled trials
comparing surgical and conservative treatment, there seems to be greater
agreement that hematomas greater than 3—4 cm should be operated upon,
especially when there is concomitant clinical deterioration or
hydrocephalus", according to the study of Surgical treatment of
intracerebral haemorrhage by University of Newcastle upon Tyne,
Newcastle upon Tyne, UK (19).
Sources
(1)
http://www.biomedcentral.com/1471-2377/7/1
(2)
http://www.ncbi.nlm.nih.gov/pubmed/22626015
(3)
http://www.ncbi.nlm.nih.gov/pubmed/19349602
(4)
http://www.ncbi.nlm.nih.gov/pubmed/21712666
(5)
http://www.ncbi.nlm.nih.gov/pubmed/21952219
(6)
http://www.ncbi.nlm.nih.gov/pubmed/18417974
(7)
http://diseases-researches.blogspot.ca/p/cerebral-aneurysm.html
(8)
http://stroke.ahajournals.org/content/36/9/1881.abstract
(9)
http://emedicine.medscape.com/article/247664-overview
(10)
http://en.wikipedia.org/wiki/Cerebral_hemorrhage
(11)
http://www.ncbi.nlm.nih.gov/pubmed/21234617
(12)
http://www.ncbi.nlm.nih.gov/pubmed/22929497
(13)
http://www.ncbi.nlm.nih.gov/pubmed/16155928
(14)
http://www.ncbi.nlm.nih.gov/pubmed/20541417?dopt=Abstract
(15)
http://www.ncbi.nlm.nih.gov/pubmed/21492631
(16)
http://www.ncbi.nlm.nih.gov/pubmed/10232539
(17)
http://www.ncbi.nlm.nih.gov/pubmed/22929484
(18)
http://www.cedars-sinai.edu/Patients/Programs-and-Services/Stroke-Program/Stroke-Resources/Cerebral-Hemorrhage.aspx
(19)
http://bmb.oxfordjournals.org/content/56/2/444.full.pdf
D.4. Subarachnoid hemorrhage (SAH)
Subarachnoid hemorrhage (SAH) is defined as a condition of the presence of blood within the
subarachnoid space (the area between the brain and the thin tissues that cover the brain).
D.4.1. Causes and Rick factors
1. Causes
a. Bleeding from an arteriovenous malformation (AVM)
There is a report of nineteen additional cases of angiographic vasospasm after
AVM
rupture are reported in the literature. The mean age of these patients
was 33 years; there was a 1.25:1 female to male predominance in this
group. One-half of these patients had an intraparenchymal
hemorrhage, and only 56% of them had SAH(1).
b. Bleeding from a cerebral aneurysm
There is a report of a 59-year-old woman with type IIA von Willebrand's disease (VWD) presented with
subarachnoid hemorrhage (SAH). Computed tomography showed SAH in the right sylvian fissure and
intracranial hemorrhage in the right temporal lobe. Angiography demonstrated an
aneurysm at the bifurcation of the right middle
cerebral artery(2).
c. Coagulopathy
In the study carried out in an attempt to find out the association of
coagulopathy and the development of delayed traumatic intracerebral hematoma (DTICH) in patients diagnosed with a traumatic
subarachnoid hemorrhage (TSAH), found that on admission, peripheral
blood samples for
coagulation
studies were taken within 6 hours after injury. All patients had
subsequent CT scans performed within 24 hours of admission. Thirty
(47.6%) of 63 patients exhibited radiological evidence of DTICH on their
subsequent CT scans. There was a significant correlation between the
increased value of serum fibrinogen degradation product (FDP > 40
micrograms/ml) and the development of DTICH(3).
d. Head injury
In the study of Coagulopathy in severe traumatic brain injury: a prospective study, found that the incidence of TBI coagulopathy in SHI is high, especially in
penetrating injuries. Independent risk factors for coagulopathy in
isolated head injuries include GCS score of <or=8, ISS >or=16,
hypotension upon admission, cerebral edema,
subarachnoid hemorrhage,
and midline shift. The development of TBI coagulopathy is associated
with longer ICU length of stay and an almost 10-fold increased risk of
death(4).
f. Use of blood thinners
There is a repory of a 45-year-old woman with prosthetic valves replacement, was admitted with
severe headache and vomiting one month after starting danazol treatment
at 300 mg per day. She was receiving long-term anticoagulation with
warfarin
and dipyridamole, taking 3.5 mg and 300 mg per day respectively. The
patient's thrombotest value was less than 6% at the time of admission.
Cranial CT revealed
subarachnoid hemorrhage(5).
g. Certain types of herb
If you are experience certain symptoms of Hemorrhaging, please consult with your doctor before taking any blood thinning herbal medicine. Moderate to severe adverse events, such as spinal epidural hematoma, spontaneous intracerebral
hemorrhage, retrobulbar
hemorrhage,
subarachnoid hemorrhage,
spontaneous hyphema, and postoperative bleeding, have occasionally been
anecdotally associated with consumption of dietary supplements(6).
h. Etc.
2. Risk factors
a, Gene defect
In the study to evaluate whether genes influencing
coagulation are associated with the occurrence of aneurysmal
subarachnoid hemorrhage (
SAH) and with secondary cerebral ischemia and rebleeding in patients with aneurysmal
SAH, showed that aneurysmal
SAH
patients are more often carriers of the subunit B His95Arg factor XIII
polymorphism compared to controls. This suggests that carriers of the
subunit B His95Arg factor XIII polymorphism have an increased risk of
aneurysmal
SAH(7).
b. von Willebrand's disease
von Willebrand's disease is associated with the onset of
subarachnoid hemorrhage (SAH)(8).
c. Vitamin K deficiency
Although late VKDB leads to significant morbidity and mortality, it can
be avoided by providing vitamin K prophylaxis to all newborns.
Administration of vitamin K (1 mg) at birth can prevent intracranial
bleeding and other hemorrhagic manifestations, according to the study by Erciyes University, Talas, Kayseri, Turkey(9).
d.
Factor XI deficiency
Aneurismal
subarachnoid haemorrhage (
SAH)
is a devastating event affecting patients at a fairly young age and
accounting for significant morbidity and mortality. Researchers at the
National and Kapodistrian University of Athensm reported a unique case
of aneurismal
SAH in a patient with underlying
coagulation FXI deficiency which was incidentally identified after patient's admission, as routine
blood
tests revealed increased activated partial thromboplastin time. Despite
early successful treatment with coiling, the patient had a second
episode of
SAH a few months after his discharge, due to aneurysm revascularization and rupture(10).
d. Etc.
D.4.2. Symptoms
1. Thunderclap headache, neck stiffness, psychosocial consequences
Classic signs and symptoms include sudden onset of '
thunderclap'
headache but patients can present with atypical symptoms such as neck stiffness. For patients who survive
SAH,
the psychosocial consequences can be devastating and can affect their
families or carers(11).
2. Head ache and Meningeal signs
In the study of 193 adult aSAH patients confirmed headache as well as meningeal signs as
the most frequent symptom on presentation to the emergency department,
and this was cited as the most common reason for seeking medical
treatment(12).
3. Confusion, seizures. impairment of language ability and vasospasm
eizures are a recognized complication of
subarachnoid hemorrhage (
SAH).
They can increase the cerebral metabolic demands and lead to
cardiopulmonary compromise. This could be detrimental in the setting of
delayed cerebral ischemia (DCI), when the brain tissue is vulnerable to
further reductions in oxygen delivery or increases in demand. An
association between
seizures and worsening ischemia could influence the decision to use antiepileptic drug (AED) prophylaxis in patients with vasospasm(13).
4. Intracranial pressure (pressure inside the skull), drop of cerebral blood flowand Cushing reflex respons, brain
edema formation, loss of hippocampal neurons, neurological dysfunction
SAH induced a sharp increase of
intracranial pressure
(ICP) from 5.1+/-1.2 to 78.5+/-9.3 mm Hg (mean+/-SD; p<0.05), a
concomitant drop of cerebral blood flow (rCBF) by 81+/-4% (p<0.05),
and a significant Cushing reflex response (p<0.05). rCBF measurements
alone could not reliably detect SAH. SAH resulted in significant brain
edema formation (brain water content increase at 72 h: 2.9+/-0.9%;
p<0.05), loss of hippocampal neurons (CA1: -56%, CA2: -55%; CA3:
-72%; 7 days; p<0.05), severe neurological dysfunction over 7 days,
and a mortality of 30%.
(14).
5. Other symptoms
There is a report of a 50-year-old male patient suffered from
subarachnoid hemorrhage (
SAH).
No abnormal condition was found in intracranial vascular digital
subtraction angiography (DSA). But, this patient presented with positive
hantavirus-IgM and IgG, with typical clinical process, which lead to
the diagnosis of EHF followed by
SAH.
Meticulous assessment of EHF patients with a serious condition had one
or more central nervous system (CNS) abnormalities, such as
sudden
headache, vomiting, confusion,
meningismus, and convulsions, which is
necessary for diagnosing and giving timely
treatment to improve the prognosis(14a).
D.4.3. Diagnosis
1. Computed tomography (CT) scan or multidetector CT angiography
If your doctor suspects the bleeding is within the brain itself, then
CT scan is the best choice. Computed tomography (CT)
is the standard diagnostic tool uses
X-rays to make detailed pictures of structures inside the skull to
check for fractures and bleeding, specially in case of trauma. Scheduled repeat head
computed tomography
after mild traumatic brain injury has been shown to have limited use
for predicting the need for an intervention. CT scan has correctly identified over 95% of cases—especially on the first day after the onset of bleeding. Others suggested that multidetector CT
angiography can be used as a primary examination tool in the diagnostic work-up of patients with SAH(15).
2. A Lumbar puncture
If CT scan can not identify the diagnosis, your doctor may suggest a lumbar
puncture (spinal tap). In the study to evaluate the Differentiation of early
subarachnoid hemorrhage from traumatic
lumbar puncture, showed that the 0.3 to 7% hemolysis which occurred was relatively independent both
of the time following SAH and of the number of red blood cells (rbc) in
the cerebrospinal fluid (CSF). There was, on the other hand, a
significant and time-dependent increase in CSF lactate concentration
early after SAH, suggesting the potential clinical value of the
detection of increased lactate with a relatively normal lactate/pyruvate
ratio in hemorrhagic CSF. Until this can be evaluated in human
subjects, however, determination of the
rbc counts or total
hemoglobin
concentrations in serially collected samples of CSF remains the best
clinical method(16).
3. ECG
ECG is found to be important in differetiating of SAH. In the study to evaluate all patients admitted to a 31-bed department of intensive care between
1993 and 2000 with acute aneurysmal SAH documented by cerebral
angiography or autops, indicated that of 159 patients (49.6 years [range: 20-75]) with acute SAH, 106 (66.7%)
had abnormal ECGs (classified by an observer blinded to the patients'
clinical course and outcome. Conduction abnormalities were present in
7.5%. Arrhythmias occurred in 30.2%. By univariate analysis, the
presence of ST depression was related to outcome as assessed by the
Glasgow Outcome Scale (GOS) (15% poor outcome [GOS 4-5] vs. 1% good
outcome [GOS 1-3], p<0.05)(17).
4. Etc.
D.4.4. Complications and diseases associated with SAH
1. Changes in coagulative and fibrinolytic activities
Both coagulative and fibrinolytic activities were altered after the onset of
SAH.
These results demonstrate that the coagulative/fibrinolytic cascade
might be activated via different mechanisms in different types of stroke(18).
2. Terson's Syndrome
TS was diagnosed in 20 of 155 SAH patients (30 eyes), and detected in 16
(14.16%) of 113 patients with aneurysmal SAH and four (9.52%) of 42
patients with traumatic SAH. No correlations were found between
state-of-
consciousness,
GCS scores, and presence of TS in patients with traumatic SAH. Among
patients suffering from aneurysmal SAH, however, significant
relationships were observed between state-of-
consciousness,
GCS scores, Hunt-Hess grades, and incidence of TS (p < 0.01). No
statistically significant difference was observed between men and women
with regard to the incidence of TS (χ(2) = 0.821, p = 0.365)(19).
3. Fahr's Disease
there is a report of a case of an acute IBCG presentation in which the cause of the deterioration was an aneurysmal
subarachnoid hemorrhage(20).
4. Hydrocephalus
Hydrocephalus, also known as "water in the brain" is defined as
complex and multifactorial neurological disorders of accumulation of
cerebrospinal fluid (CSF) in the cavity of brain of that can lead to
intracranial pressure inside the side, resulting of
brain trauma, stroke, infection, tumor, etc. Acute
hydrocephalus is present in 20% of patients with
subarachnoid hemorrhage. One third of them may be asymptomatic on admission; 50% of those who have clinical
hydrocephalus recover spontaneously within the first 24 h. The presence of acute
hydrocephalus after
subarachnoid hemorrhage is associated with additional morbidity and higher mortality secondary to rebleeding(21).
5. Etc.
D.4.4. Treatments
1. Surgery
a. Clipping
In the study of the data of patients with SAH who underwent aneurysmal clipping at the
Kartal Training and Research Hospital between 1999 and 200, showed that early
surgery is advantageous over late
surgery in patients with SAH with lower post-
operative vasospasm and mortality rates(22).
b. Coiling
In the study of 15 patients with high-risk intracranial saccular aneurysms treated using electrolytically detachable coils introduced via an
endovascular approach. The patients ranged in age from 21 to 69 years.
The most frequent clinical presentation was subarachnoid hemorrhage
(eight cases). Considerable thrombosis of the aneurysm (70% to 100%) was
achieved in all 15 patients, and preservation of the parent artery was
obtained in 14. Although temporary neurological deterioration due to the
technique was recorded in one patient, no permanent neurological
deficit was observed in this series and there were no deaths. It is
believed that this new technology is a viable alternative in the
management of patients with high-risk intracranial saccular aneurysms.
It may also play an important role in the occlusion of aneurysms in the
acute phase of subarachnoid hemorrhage(23).
c. Fenestration of the lamina terminalis and removal of cisternal clots
In the study to investigate
the effects of clot removal on multiple outcome variables following the clipping of ruptured anterior communicating aneurysms, showed that vasospasm affected 5 of 17 (29%) in group A and 8 of 13 (61.5%) in group
B (p < 0.05). Endovascular treatment for vasospasm was required in
one patient in group A (5.8% of 17, 20% of 5) and in five from group B
(38.4% of 13, 62.5% of 8) (p < 0.05). Mortality was observed in one
case in group A (5.8% of 17, 20% of 5) and in two cases in group B
(15.3% of 13, 25% of 8) and was related to vasospasm after SAH.
Ventriculoperitonal shunt (VPS) was required in one case in group A
(5.8%) and in five cases in group B (38.4%). Conclusions:
Fenestration of the lamina terminalis and removal of cisternal clots
significantly decreased the incidence of post-SAH
hydrocephalus and was associated with better outcomes(24).
2. Other Treatments
The preference of
medication
with poor clinical evidence, such as
magnesium sulfate,
aspirin,
statins, and
anti-fibrinolytics was lower than 10%. The use of
intravenous nimodipine and
systemic glucocorticoids was as high as 31%.
The availability of
endovascular therapy was 69%. The indication for
treatment of patients with unruptured intracranial aneurysms that
required intervention was less than 13.8%. In patients with ruptured or
unruptured intracranial aneurysms,
coiling was the preferred method for
exclusion, according to a a sample of members from the Colombian Association of Neurosurgery(25)
3. Etc.
Sources
(1)
http://www.ncbi.nlm.nih.gov/pubmed/22381269
(2)
http://www.ncbi.nlm.nih.gov/pubmed/16377951
(3)
http://www.ncbi.nlm.nih.gov/pubmed/11260889
(4)
http://www.ncbi.nlm.nih.gov/pubmed/19131806
(5)
http://www.ncbi.nlm.nih.gov/pubmed/1886315
(6)
http://www.ncbi.nlm.nih.gov/pubmed/22300597
(7)
http://www.ncbi.nlm.nih.gov/pubmed/19826759
(8)
http://www.ncbi.nlm.nih.gov/pubmed/16377951
(9)
http://www.ncbi.nlm.nih.gov/pubmed/21928065
(10)
http://www.ncbi.nlm.nih.gov/pubmed/19367158
(11)
http://www.ncbi.nlm.nih.gov/pubmed/20437757
(12)
http://www.ncbi.nlm.nih.gov/pubmed/22578393
(13)
http://www.ncbi.nlm.nih.gov/pubmed/21427775
(14)
http://www.ncbi.nlm.nih.gov/pubmed/20457182
(14a)
http://www.ncbi.nlm.nih.gov/pubmed/22135608
(15)
http://www.ncbi.nlm.nih.gov/pubmed/20935079
(16)
http://www.ncbi.nlm.nih.gov/pubmed/906062
(17)
http://www.ncbi.nlm.nih.gov/pubmed/15301889
(18)
http://www.ncbi.nlm.nih.gov/pubmed/16671428
(19)
http://www.ncbi.nlm.nih.gov/pubmed/22913767
(20)
http://www.ncbi.nlm.nih.gov/pubmed/22754741
(21)
http://www.ncbi.nlm.nih.gov/pubmed/9586937
(22)
http://www.ncbi.nlm.nih.gov/pubmed/22368972
(23)
http://thejns.org/doi/abs/10.3171/jns.1991.75.1.0008
(24)
http://www.ncbi.nlm.nih.gov/pubmed/22890652
(25)
http://www.ncbi.nlm.nih.gov/pubmed/22059120
E. Pulmonary hemorrhage (P-Hem)
Pulmonary hemorrhage is defined as a acute condition of lung
bleeding from the from the upper respiratory tract or the endotracheal tube of the lung with the mortality of 30 to 40%.
E.1. Causes and Rick factors
A. Causes
1. Pulmonary Embolism
In the study to determine the characteristics of the history, physical examination,
chest radiograph, electrocardiogram, and the ventilation/perfusion
lung scan probability in elderly patients with
pulmonary embolism who present with the syndrome of
pulmonary infarction or
hemorrhage, found that although a few clinical features of the
pulmonary hemorrhage/infarction syndrome of
pulmonary embolism
in elderly patients differ from patients less than 40 years of age, in
general, the clinical characteristics are comparable to younger
patients(1).
2. Bacteria infection
Enterovirus 71 (EV71)
infection with
pulmonary edema or
pulmonary hemorrhage as a fulminant and often fatal illness(2). Others report a case of a 63-year-old woman treated by intensive chemotherapy for
acute myeloid leukemia (AML) who presented while severely neutropenic
and thrombocytopenic a Sm
pulmonary infection with hemoptysis leading to death in 48 h, according to the study of Lethal
pulmonary hemorrhage caused by a fulminant Stenotrophomonas maltophilia respiratory
infection in an acute myeloid leukemia patient(3).
3. Lung cancer
In the study to investigate the risk factors associated with fatal
pulmonary hemorrhage (PH) in patients with locally advanced non-small cell
lung cancer (NSCLC), treated with chemoradiotherapy, showed that f the 583 patients, 2.1% suffered a fatal PH. The numbers of patients
with minimum, minor, and major cavitations were 13, 11, and 14,
respectively. Among the 38 patients with tumor cavitation, all 3
patients who developed fatal PH had major cavitations. On multivariate
analysis, the presence of baseline major cavitation (odds ratio,
17.878), and a squamous cell histology (odds ratio, 5.491) proved to be
independent significant risk factors for fatal PH. Interestingly, all
patients with fatal PH and baseline major cavitation were found to have
tumors with squamous cell histology, and the occurrence of fatal PH in
patients having both risk factors was 33.3%(4).
4. Pneumonia
In the review of the epidemiological, clinical and diagnosis findings of
pneumonia and
pulmonary hemorrhage
observed in patients with leptospirosis in the period January 2007 to
October 2009. A 64% (20/31) of patients diagnosed with leptospirosis
presented
pneumonia. Fifteen of them (75%) had severe
pneumonia, of which seven (35%) were
pulmonary hemorrhage.
In ten patients (32%) reason for consultation and clinical early stage
was a secretory gastroenteritis with fever and abdominal pain. Jaundice
was only expressed in eleven patients (35%)(5).
5. Etc.
B. Risk factors
1. Extreme
Exercise
There is a report of Exercise-induced pulmonary hemorrhage (EIPH) occurs in horses that race at high speeds(6)
2. Hereditary hemorrhagic telangiectasia and others
Hereditary hemorrhagic telangiectasia (Osler-Weber- Rendu disease) is inherited as an autosomal dominant trait with an incidence as high as 1:2300, according to the study of Hereditary hemorrhagic telangiectasia with pulmonary arteriovenous malformations. Prematurity is the factor most commonly associated with P-Hem; other associated factors are those that predispose to
perinatal asphyxia or
bleeding disorders, including
toxemia of pregnancy, maternal cocaine use,
erythroblastosis fetalis,
breech delivery,
hypothermia,
infection,
Respiratory Distress Syndrome, administration of exogenous
surfactant (in some studies) and
ECMO(7).
3. Etc,
E.2. Symptoms
1. The onset of P-Hem is characterized by oozing of bloody fluid from the nose and mouth or endotracheal tube with associated rapid worsening of the
respiratory status,
cyanosis and, in severe cases,
shock(7).
2.
In the report of 3 cases of enterovirus 71
infection with
pulmonary edema or
pulmonary hemorrhage as the early clinical manifestation, found that
pulmonary edema or
pulmonary hemorrhage
occurred in the 3 cases with EV71-infected infants. The initial
presentation was often nonspecific with
fever and vomiting, and
sudden
appearances of cyanosis, tachypnea, tachycardia, hypertension or
hypotension,
limb weakness may suggest
pulmonary edema or
hemorrhage.
Excessive fluid resuscitation may deteriorate the illness, on the
contrary,
fluid restriction and inotropic agents, and early
intubation
with positive pressure mechanical ventilation may be the proper
treatment(8).
3. Etc.
E.3. Diagnosis
1. The computed tomography (CT) scans and chest radiograph
In the study of the computed tomography (CT) scans and chest radiograph of seven
patients with bronchoscopic or pathologically proven cases of pulmonary
hemorrhage to determine the appearance and value of each
modality, showed that CT revealed the presence and location in all cases while chest
radiographs were falsely negative in two cases. The CT pattern was
always an alveolar pattern while the pattern was more variable on chest
radiographs. By providing better pattern definition than the chest
radiographs, CT is the study of choice in detecting the presence of a
suspected pulmonary hemorrhage(9).
2. Bronchoalveolar lavage (BAL)
Bronchoalveolar lavage (BAL) is a medical procedure to collect and examine the lung fluid with the use of a bronchoscope, passing through the mouth or nose into the lungs. In the study to investigate the efficacy of bronchoalveolar lavage (BAL) in diagnosing
pulmonary hemorrhage in 51 immunosuppressed patients with new
pulmonary infiltrates, showed that Severe
pulmonary hemorrhage was ultimately diagnosed in 14 cases, and a mild degree of
hemorrhage was found in an additional 19 cases. Thrombocytopenia and invasive fungal infections were statistically associated with severe
hemorrhage, as was an increased percentage of alveolar macrophages in the BAL sample(10).
3. CT-guided transthoracic lung biopsy
Higher rates of complications are significantly found with
multiple
punctures (pneumothorax risk multiplied by 7.4),
longer
intra-parenchymal needle tract (5 and 7% higher risk of
pneumothorax and
hemorrhage for every 1 mm increase in depth), and with smaller lesions (2 and 5% lower risk respectively for pneumothorax and
hemorrhage for every 1 cm increase in lesion size). The presence of an interposing rib is associated with a higher rate of
hemorrhage(11).
4. Etc.
E.4. Complication
1. Leptospirosis
Leptospirosis is a widespread zooanthroponosis that is prevalent in tropical regions due to the
favorable environmental survival conditions of its etiologic agent (Leptospira)(12).
2. Fetomaternal complications
Antenatal diagnosis and treatment of women with hereditary hemorrhagic telangectasia and pulmonary arteriovenous malformations might prevent potentially lifethreatening fetomaternal complications(13).
3. Pulmonary infection and respiratory failure
In the study of spinal cord injury (SCI) rats,
pulmonary edema and
hemorrhage were occurred in the early stage of SCI while the other organs were almost normal. And the location of
lung edema and
hemorrhage were the same as that of
pulmonary infection(14).
4. Etc.
E.4. Treatments
Treatments depend on the diagnosis of each patient, if the underlined cause is due to medication, then medicine has to be stopped.
1. Immediate treatment
According to the Intensive Care Nursery House Staff Manual immediate treatment of P-Hem should include tracheal suction, oxygen and positive pressure ventilation. To assist in decreasing P-Hem, mean
airway pressure should be increased, either by a relatively high PEEP (i.e., 6 to 10
cmH2O) or by high frequency ventilation(15). In the infants, reserachers at suggested that current management of PH in VLBW infants includes ventilatory support using high
positive end expiratory pressure, transfusion of blood and blood
products to support the circulation and correct any hemostatic or
coagulation defects and evaluation and treatment for patent ductus
arteriousus (PDA). These strategies are often ineffective in preventing a poor outcome. rFVIIa is effective in controlling life-threatening hemorrhage in patients
with hemophilia A and B with inhibitors,
and in
nonhemophiliacs with a variety of inherited or acquired
hemostatic defects including
platelet disorders,
liver disease and von
Willebrand's disease.(15a)
2. Embolization - Interventional treatment of pulmonary arteriovenous malformations
Acording to the study of Dr. Andersen PE and Dr. Kjeldsen AD. at the Odense University Hospital "
Pulmonary
arteriovenous malformations (PAVM) are congenital vascular
communications in the lungs. The generally accepted treatment strategy of first choice is
embolization of the afferent arteries to the arteriovenous
malformations. It is a minimally invasive procedure and at the same time
a
lung
preserving treatment with a very high technical success, high
effectiveness and low morbidity and mortality. Embolization prevents
cerebral stroke and abscess as well as
pulmonary haemorrhage
and further raises the functional level. Embolization is a
well-established method of treating PAVM, with a significant effect on
oxygenation of the blood. Screening for PAVM in patients at risk is
recommended, especially in patients with HHT(16).
3. Corticosteroids
There is a report of a
patient suffered from acute
glomerulonephritis with modest renal impairment and life-threatening
pulmonary hemorrhage. The pulmonary hemorrhage caused severe hypoxia
that necessitated artificial ventilation. As a last resort, 1 g/day of
methylprednisolone was administered intravenously. Rapid cessation of
pulmonary hemorrhage ensued with clearing of the lungs fields. the
suggestion of large doses of glucocorticosteroids should be administered
to patients with life-threatening pulmonary hemorrhage before
considering bilateral nephrectomy, especially if the renal function is
still adequate. Bilateral nephrectomy is an irreversible approach and,
as with massive doses of steroids, has yet to be proved to be a
consistently effective mode of therapy(17).
4. Etc.
Sources
(1)
http://www.ncbi.nlm.nih.gov/pubmed/11416457
(2)
http://www.ncbi.nlm.nih.gov/pubmed/19099810
(3)
http://www.ncbi.nlm.nih.gov/pubmed/15360016
(4)
http://www.ncbi.nlm.nih.gov/pubmed/22260460
(5)
http://www.ncbi.nlm.nih.gov/pubmed/21550928
(6)
http://www.ker.com/library/proceedings/04/EIPH_p95.pdf
(7) http://www.ucsfbenioffchildrens.org/pdf/manuals/29_PulmHemorrhage.pdf
(8) http://www.ncbi.nlm.nih.gov/pubmed/19099810
(9) http://www.sciencedirect.com/science/article/pii/089970719390021E
(10) http://www.ncbi.nlm.nih.gov/pubmed/3605828
(11) http://www.ncbi.nlm.nih.gov/pubmed/22645895
(12) http://saithan.net/pulmonary%20and%20sys%20disease/Pulmonary%20complications%20of%20leptospirosis.pdf
(13) http://ape.med.miami.edu/Doc/Resident%20Web%20Site%20Articles/Other%20diseases/Hereditary%20Hemorrhagic%20Telangiectasias/OB%20article%20+%20pulmAVMs.pdf
(14)
http://www.ncbi.nlm.nih.gov/pubmed/22683446
(15)
http://www.ucsfbenioffchildrens.org/pdf/manuals/29_PulmHemorrhage.pdf
(15a)
http://www.nature.com/jp/journal/v22/n8/full/7210787a.html
(16)
http://www.ncbi.nlm.nih.gov/pubmed/21160695
(17)
http://annals.org/article.aspx?articleid=689575
F. Vaginal bleeding
Vaginal bleeding is defined a condition of
abnormal vaginal bleeding
or spotting between periods as a result of hormonal imbalances (abnormal
uterine bleeding)
, pregnancy, menopause, diseases, bleeding disorders, medications, etc. Researchers at the 2nd Department of Obstetrics and Gynecology, University of Athen
suggested that the occurrence of irregular, prolonged or heavy abnormal
uterine bleeding is one of the most urgent gynecological problems in adolescence and the diagnosis of
dysfunctional uterine bleeding should be used only when all
other organic and structural causes of
abnormal vaginal bleeding have been ruled out(1).
F.1. Causes and Risk factors
1. Causes
a. Hormonal imbalance
Menstrual
bleeding that falls outside the range of normal is often a cause of great concern, before treating with
hormonal interventions or blood products, PCOS, should always be ruled out with clinical signs of hyperandrogenism, obesity, or insulin
resistance. Attention must also be paid to signs or a family history of
a
bleeding disorder, as vWD is commonly associated with excessive
uterine bleeding(2). Ovulatory abnormal
uterine bleeding,
or menorrhagia, may be caused by thyroid dysfunction, coagulation
defects (most commonly von Willebrand disease), endometrial polyps, and
submucosal fibroids. Transvaginal ultrasonography or saline infusion
sonohysterography may be used to evaluate menorrhagia(2a).
b. Von Willebrand disease
Von Willebrand disease is defined as
a hereditary condition of coagulation abnormality. There is a report of a 17 year old woman presented with severe anaemia due to menorrhagia. On
investigation, she was shown to have abnormalities of her haemostatic
mechanism consistent with
von Willebrand's
disease Type I, although there was no family history of this disorder(3).
c. cervical cancer
In the study to determine the presentation, pathological findings, treatment, and outcome of patients with cervical sarcom, f 1804 patients in the study with cervical malignancies, 8 cervical sarcomas were identified. All patients presented with
vaginal bleeding and discharge(4).
d. Birth control pill
The Pill normally is prescribed by your doctor to reduce the heavy
period blood for woman as well as in treating of period pain, or for
contraceptive purpose ( 21 days on and 7 days off). Oral contraception
is the dominant method of contraception for women in the world wide, in
Canada there is more than 43% of sexually active women use it. It is
defined as
medications taken by mouth to prevent unwanted pregnancy. Bleeding and spotting is normal for the first six months for women
starting any oral contraceptive combination pill because our body needs
time to adjust to the new medication(5).
e. Endometrial hyperplasia
Endometrial hyperplasia is a condition of over growth of endometrial cell causing too thick of the endometrium of that can lead to abnormal bleeding. Researchers at the Department of Pathology, Aarhus University Hospital found that the mean (+/-s.d.)
endometrial thickness was significantly different in patients with
hyperplasia
11.5 mm (+/-5.0), polyps 11.8 mm (+/-5.1), sub-mucous myomas 7.1 mm
(+/-3.4) and in patients without these abnormalities(abnormal uterine bleeding) 8.37 (+/-3.9)
(p<0.001)(6).
f. Intrauterine device (IUD)
Researchers at the School of Medicine, Zhejiang University, in the study of the expression of angiopoietin-1 and -2 in the endometrium of women with abnormal
bleeding induced by an intra-
uterine device, found that Immunohistochemical analysis showed elevated Ang-2 protein levels in secretory phase endometrium from
IUD
patients compared with the control women. These results suggest that
the angiopoietin/Tie-2 system promotes vascular remodelling in the
endometrium and that changes in the expression of Ang-1, Ang-2 and Tie-2
may contribute to abnormal
uterine bleeding in some
IUD users(7).
h. Miscarriage or ectopic pregnancy
h.1. Miscarriage
Miscarriage is defined as the loss of an embryo before the 20th week of pregnancy as
it is incapable of surviving independently. In
medical terminology, miscarriage is a type of abortion, as it refers
to the pregnancy ends with the death and removal or expulsion of the
fetus, regardless of whether it is spontaneous or medically induced
abortion. In US alone,
over 15% of pregnancy ends in miscarriage.
Most common symptoms of miscarriage. 50% of bleeding during 20 weeks of pregnancy ends in miscarriage(8).
h.2. Ectopic pregnancy
Ectopic pregancy is defined as a condition in which
the fertilized implant in somewhere else other than in the uterus. In
most case, ectopic pregnancy occurrs in the one of the Fallopian tube,
causinf tubal pregnancy. Ectopic pregnancy will end up in miscarriage as
the fertilized can not survive outside of uterus. Bleeding occurs between 6 - 8 weeks of pregnancy may be a sign of
miscariage due to the implant egg inability to survive out side of
uterus(9).
i. Amenorrhea, age, PID, fibroids and ovarian masses
In the document sonographically identifiable causes of
vaginal bleeding in secondarily amenorrhoeic women of child bearing age, showed that 75(73.2%) patients had pregnancy-related conditions, 14(13.7%) had
normal, non-pregnant uteri while the remaining 13 (12.8%) had other
gynaecological conditions namely
pelvic inflammatory disease (PID),
uterine fibroids and
ovarian masses. Though pregnancy-related conditions are the major causes of
vaginal bleeding in amenorrhoeic women of childbearing age,
PID, fibroids and ovarian masses are possible findings(10).
j. Polycystic ovary syndrome
Polycystic Ovarian Syndrome is defined as endocrinologic diseases
caused by undeveloped follicles clumping on the ovaries that interferes
with the function of the normal ovaries as resulting of enlarged
ovaries, leading to hormone imbalance( excessive androgen), resulting
in male pattern hair development, acne,irregular period or absence of
period, weight gain and effecting fertility. It effects over 5% of
women population or 1 in 20 women(11).
h. Etc.
2. Risk factors
a. Physical, psychological and environmental factors
questionnaire survey was conducted on 14,752 women by trained doctors,
when pregnant women came for the first antenatal examination, including
sociodemographic characteristics, prior
adverse pregnancy outcomes,
diseases history, life event stress, adverse environmental exposure and detailed information on VB(12).
b. Age
The rate of postmenopausal
vaginal bleeding during the study period peaks at the
age of 55-59 years (25.9/1000 postmenopausal women/year) and declines thereafter(13).
c. Medical conditions and medication
People who have had medical conditions such as thyroid and pituitary disorders, diabetes, cirrhosis of the liver, and systemic lupus erythematosus or taken certain medication such as steroids or blood thinnersare at incresed risk of vaginal bleeding(14)
d. Inherited bleeding disorders (IBDs)
Inherited
bleeding
disorders (IBDs) are by definition life-long. Women with IBDs are more likely to suffer HMB, to be symptomatic, and to present with
bleeding in association with gynaecological problems. Heavy and/or abnormal menstrual
bleeding increases with age due increased anovulatory cycles and gynaecological pathologies in older women(15).
d. Etc.
3. Symptoms
a. Bleeding or spotting between periods
b. Bleeding after sex
In most case, it is caused by sexual transmitting diseases
c. Irregular menstruation (menstrual cycle less than 28 days (more common) or more than 35 days apart)
d. Variable menstrual flow ranging from scanty to profuse
e. Menopausal bleeding
f. Etc.
F.3. Diagnosis
After a complete physical exam, including pelvic examination and questions related to your general health, including episode of vaginal bleeding, last normal menstrual cycle, previous abnormal bleeding, use of birth control pill, numbers of sexual partners, history of abnormal bleeding, etc.
a. Bacteria culture
If you are experience vaginal bleeding, bacteria cultire may be the first that you doctor orders to rule out sexually transmitted diseases such as gonorrhea and chlamydia.
b. Pap smear
To rule out irregular cervicl cell growth cause of vaginal bleeding
c. Endometrial biopsy
If you doctor suspect that the bleeding is of result of endometrial cells overgrowth.
d. Pelvic ultrasound
Pelvic ultrasound allows your doctor to examine the structures and organs in the lower abdomen and pelvis with an aim to find the underlined causes of vaginal bleeding
e. Blood tests such as thyroid function tests, complete blood count
To rule out Ovulatory abnormal
uterine bleeding caused by thyroid dysfunction, coagulation
defects (most commonly von Willebrand disease.
f. Pregnancy test
the aim of the Pregnancy test is to rule out the bleeding caused by complication of pregnancy,
g. Etc..
F.4. Treatments
Treatments depends to the finding of the underlined causes of vaginal bleeding, such as
F4.1. Fibroids and uterine bleeding
http://medicaladvisorjournals.blogspot.ca/2011/08/menstrual-conditionsirregularities.html
F.4.2. Endometriosis
http://medicaladvisorjournals.blogspot.ca/2011/12/endometriosis.html
F.4.3. Ectopic pregnancy
http://medicaladvisorjournals.blogspot.ca/2012/01/ectopic-pregnancy.html
F.4.4. Polycystic ovary syndrome
1. In Conventional Medicine Perspective
2.In Traditional Chinese Medicine Perspective
3. In Weight Loss Perspective
4. Permanently Eliminate All Types of Ovarian Cysts and PCOs Within 2 Months for Only $4?
F.4.5. Pelvic Inflammation Disease
1. In conventional medicine perspective
2. In Trsditional Chinese medicine Perspective
Sources
(1) http://www.ncbi.nlm.nih.gov/pubmed/22846527
(2) http://www.ncbi.nlm.nih.gov/pubmed/22764555
(2a) http://www.ncbi.nlm.nih.gov/pubmed/22230306
(3) http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014910/
(4) http://www.ncbi.nlm.nih.gov/pubmed/22740005
(5) http://medicaladvisorjournals.blogspot.ca/2012/01/oral-contraception-pill-combined-oral.html
(6) http://www.ncbi.nlm.nih.gov/pubmed/11437723
(7) http://www.ncbi.nlm.nih.gov/pubmed/20233519
(8) http://medicaladvisorjournals.blogspot.ca/2012/01/miscarriage.html
(9) http://medicaladvisorjournals.blogspot.ca/2012/01/ectopic-pregnancy.html
(10) http://www.ncbi.nlm.nih.gov/pubmed/18923588
(11)
http://medicaladvisorjournals.blogspot.ca/2012/01/overcome-infertility-fertility-and_13.html
(12) http://www.ncbi.nlm.nih.gov/pubmed/22584214
(13)
http://www.ncbi.nlm.nih.gov/pubmed/20424279
(14)
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014910/
(15)
http://www.ncbi.nlm.nih.gov/pubmed/22445218
G. Postpartum hemorrhage
Postpartum hemorrhage (PPH) is a loss of blood greater than 500 ml, following vaginal delivery, or 1000 ml, following cesarean section.The mortility rate is of 1000 women per 100,000 live births as a result of Postpartum hemorrhage (PPH). In the evaluation of all randomly assigned participants,active bleeding was
controlled within 20 min with study treatment alone for 440 (90%) women
given misoprostol and 468 (96%) given oxytocin (relative risk [RR] 0·94,
95% CI 0·91—0·98; crude difference 5·3%, 95% CI 2·6—8·6). Additional
blood loss of 300 mL or greater after treatment occurred for 147 (30%)
of women receiving misoprostol and 83 (17%) receiving oxytocin (RR 1·78,
95% CI 1·40—2·26). Shivering (229 [47%]
vs 82 [17%]; RR 2·80, 95% CI 2·25—3·49) and fever (217 [44%]
vs
27 [6%]; 8·07, 5·52—11·8) were significantly more common with
misoprostol than with oxytocin. No women had hysterectomies or died(1).
G.1. Causes and Risk factors
1. Causes
Causes of Postpartum hemorrhage (PPH) are of result of uterine atony, trauma, retained placenta, and coagulopathy(4Ts)
a. Uterine atony
Uterine atony is a loss of functions of compression of the vessels to reduce blood flow after child birth. According to the study of Department of Obstetrics and Gynecology, Duke University School of Medicine, omen with severe
PPH
had a mean oxytocin area under the curve of 10,054 mU compared to 3762
mU in controls (P < .001). After controlling for race, body mass
index, admission hematocrit, induction status, magnesium therapy, and
chorioamnionitis using logistic regression, oxytocin area under the
curve continued to predict severe
PPH(2).
b. Trauma
Trauma due to a body wound or shock as a sudden physical injure such as car accidence are associated to the to the cause of Postpartum hemorrhage (PPH.Uncontrolled bleeding continues to be a major cause of mortality in
trauma, cardiac surgery,
postpartum hemorrhage and liver failure, according
to the study of Use of Activated Recombinant Factor VII in Severe Bleeding - Evidence for Efficacy and Safety in
Trauma,
Postpartum Hemorrhage, Cardiac Surgery, and Gastrointestinal Bleeding(3).
c. Tissues
Blood clots or retained tissues after birth, including retained placenta accounts for 10% of PPH. The
primary tissue-based etiology of PPH is retained placenta. In the study of intravenous sulprostone infusion in the treatment of
retained placenta, showed that the
placenta was successfully expelled in 39.7% of cases, whereas 60.3% of women underwent manual removal of
placenta. Blood loss was significantly lower in women with successful placental expulsion than in women who had manual removal of the
placenta (582 ± 431 ml vs. 1275 ± 721 ml, p < 0.0001). Sulprostone infusion did not cause adverse effects or significant
postpartum morbidity(4).
d. Coagulopathy
Coagulopathy is defined as a condition of coagulation abnormalities in which blood clots fail to form. According to the study by the Duke University Medical Center, Durham, systemic bleeding at the time of
postpartum hemorrhage (PPH) is usually the result of
coagulopathy that has developed acutely as a result of massive
hemorrhage after uterotonics and sutures have failed(5).
e. Etc.
2. Risk factors
a. In vaginal delivery
According to the study of University of Uruguay, Montevideo, Uruguay, moderate and severe
postpartum hemorrhage occurred in 10.8% and 1.9% of deliveries, respectively. The
risk factors more strongly associated and the incidence of moderate
postpartum hemorrhage in women with each of these
factors
were: retained placenta (33.3%) (adjusted odds ratio [OR] 6.02, 95%
confidence interval [CI] 3.50-10.36), multiple pregnancy (20.9%)
(adjusted OR 4.67, CI 2.41-9.05), macrosomia (18.6%) (adjusted OR 2.36,
CI 1.93-2.88), episiotomy (16.2%) (adjusted OR 1.70, CI 1.15-2.50), and
need for perineal suture (15.0%) (adjusted OR 1.66, CI 1.11-2.49).
Active management of the third stage of labor, multiparity, and low
birth weight were found to be protective
factors. Severe
postpartum hemorrhage
was associated with retained placenta (17.1%) (adjusted OR 16.04, CI
7.15-35.99), multiple pregnancy (4.7%) (adjusted OR 4.34, CI
1.46-12.87), macrosomia (4.9%) (adjusted OR 3.48, CI 2.27-5.36), induced
labor (3.5%) (adjusted OR 2.00, CI 1.30-3.09), and need for perineal
suture (2.5%) (adjusted OR 2.50, CI 1.87-3.36)(6).
b. In caesarean section
caesarean section is associated to increased risk of recurrent massive uterine bleeding, according to the report of a 37 yr old patient suffered severe atonic bleeding requiring different
operating procedures (Clipping of the uterine arteries) in combination
with an uterotonic and haemostaseological medication as well as massive
transfusion of blood components and recombinant factor VIIa. After a
period of 17 days without any bleeding the patient presented to the
emergency room with recurrent massive uterine bleeding(7).
c. Racial and ethnic disparities
Hispanic ethnicity and Asian/Pacific Islander race were associated with a
statistically significant increased odds of atonic PPH in comparison
with Caucasians, despite adjustment for potential mediators (adjusted
odds ratio [OR] for Hispanics: 1.21, 99% confidence interval [1.18,
1.25]; for Asians/Pacific Islanders: 1.31 [1.25, 1.38], with Caucasians
as reference)(8).
d. Others risk factors
According to the study of Risk Factors for Postpartum Hemorrhage: Can We Explain the Recent Temporal Increase?, major independent risk factors for PPH included
primiparity, prior Caesarean section, placenta previa or low-lying placenta,
marginal umbilical cord insertion in the placenta,
transverse lie, labour induction and augmentation, uterine or cervical trauma at delivery, gestational age < 32 weeks, and birth weight ≥ 4500 g. An overall increase in rate of PPH over the study period (OR 1.029; 95% CI 1.024 to 1.034 per year) disappeared (OR 0.995; 95% CI 0.988 to 1.001 per year) after inclusion of maternal age, parity, prior Caesarean section, labour induction and augmentation, placenta previa or low-lying placenta, and abnormal placenta, with most of the reduction attributable to rises in previous Caesarean section and labour augmentation(9). Also according to
the length of the third stage of labor and the risk of postpartum hemorrhage, Obstet Gynecol.
2005;105:290–3 and Stones
RW,
Paterson
CM,
Saunders
NJ.
Risk factors for major obstetric haemorrhage.
Eur J Obstet Gynecol Reprod Biol.
1993;48:15–8., risk factors for postpartum hemorrhage also include a prolonged
third stage
of labor, multiple delivery, episiotomy, fetal macrosomia, and history
of postpartum hemorrhage
G.3. Prevention and management
According to the article of Active versus expectant management in the third stage of labour (Review) by Prendiville WJ, Elbourne D, McDonald S, routine ’active management’ is superior to ’expectant management’ in terms of blood loss, post partum haemorrhage and other serious complications of the third stage of labour. Active management is, however, associated with an increased risk of unpleasant side effects (eg nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in amaternity hospital. The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries)(10).
G.4. Diagnosis and Treatments
1.
Diagnosis
The aim of diagnosis is to determine the underlined causes of the disease, inmost cases , it is caused by 4Ts.
Estimation of blood loss by calibrated bags has been shown to be
significantly more accurate than visual estimation at vaginal delivery.
Careful monitoring of the mother's vital signs,
laboratory tests, in
particular coagulation testing, and immediate diagnosis of the cause of PPH are important key factors to reduce maternal morbidity and mortality(11).
2.
Treatments
According to the researchers at the Department of Obstetrics and Gynecology, Orbis Medical Centre, in the current treatment of severe PPH, first-line therapy includes
transfusion of packed cells and
fresh-frozen plasma in addition to
uterotonic medical management and
surgical interventions. In persistent
PPH,
tranexamic acid,
fibrinogen, and coagulation factors are often administered. Secondary
coagulopathy
due to PPH or its treatment is often underestimated and therefore
remains untreated, potentially causing progression to even more severe
PPH. In most cases,
medical and transfusion therapy is not based on the
actual
coagulation
state because conventional laboratory test results are usually not
available for 45 to 60 minutes.
Thromboelastography and rotational
thromboelastometry are point-of-care
coagulation tests. A good correlation has been shown between thromboelastometric and conventional
coagulation
tests, and the use of these in massive bleeding in nonobstetric
patients is widely practiced and it has been proven to be
cost-effective.
Fibrinogen
seems to play a major role in the course of PPH and can be an early
predictor of the
severity of PPH. The FIBTEM values (in
thromboelastometry, reagent specific for the fibrin polymerization
process) decline even more rapidly than fibrinogen levels and can be
useful for early guidance of interventions(12).
Sources
(1)
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2961924-3/abstract
(2)
http://www.ncbi.nlm.nih.gov/pubmed/21047614
(3)
http://www.ncbi.nlm.nih.gov/pubmed/22670132
(4)
http://www.ncbi.nlm.nih.gov/pubmed/22862433
(5)
http://www.ncbi.nlm.nih.gov/pubmed/22430921
(6)
http://www.ncbi.nlm.nih.gov/pubmed/19461428
(7)
http://www.ncbi.nlm.nih.gov/pubmed/22628026
(8)
http://www.ncbi.nlm.nih.gov/pubmed/22886840
(9)
http://jogc.com/abstracts/full/201108_Obstetrics_5.pdf
(10)
http://apps.who.int/rhl/reviews/CD000007.pdf
(11)
http://www.ncbi.nlm.nih.gov/pubmed/21332452
(12)
http://www.ncbi.nlm.nih.gov/pubmed/22430921
H. Breakthrough bleeding
Breakthrough bleeding is defined as a condition of an abnormal flow of blood from the uterus that occurs between menstrual periods especially due to irregular sloughing of the endometrium in women on contraceptive hormones(1).
H.1. Causes and Risk factors
1. Excessive thick uterine lining (edometrium)
During the last stage of the menstrual cycle, normally a layer of endometriosis lining on the inside of the uterus is expelled, known as menstruation blood. In some women, excessive thick of uterine lining (edometrium) may cause breakthrough bleeding.
2. Hormonal fluctuations
Fluctuating hormones around ovulation may experience breakthrough bleeding.
3. Taking oral contraceptives
In the study of dilated thin-walled blood and lymphatic vessels in human
endometrium: a potential role for VEGF-D in progestin-induced break-through
bleeding, researchers at the Department of Obstetrics and Gynaecology and Monash Institute for Medical Research, Monash University, wrote that using a NOD/scid mouse model with xenografted human
endometrium
we were able to show that progestin treatment causes decidualisation,
VEGF-D production and endometrial vessel dilation. Our results lead to a
novel hypothesis to explain BTB, with stromal cell decidualisation
rather than progestin treatment per se being the proposed causative
event, and VEGF-D being the proposed effector agent(2).
4. Amenorrhea
In the study of The induction of amenorrhoea by Hipkin LJ. indicated that a survey has shown that many women favour eliminating menstruation and it has been suggested that therapeutic induction of
amenorrhoea might be an advantage in female personnel mobilised for war, but it poses some side effects including
bleeding and spotting, 2 kg weight gain, breast tenderness, depression, and headaches(3).
5. Progestin treatment
Clinicians routinely prescribe progestins along with estrogens during
menopausal hormone therapy (HT) to block estrogen-dependent endometrial
proliferationmay cause breakthrough bleeding
.
6. Polyps
In teh study to determine the effectiveness of different treatments for abnormal uterine
bleeding in women with known endometrial
polyps, showed that polypectomy and other treatments of women with abnormal uterine
bleeding who had benign
polyps detected by sonohysterography. Women with endometrial
polyps
diagnosed by sonohysterography between January 1997 and July 1998 were
sent questionnaires on pretreatment and posttreatment uterine
bleeding and satisfaction with their treatments(4).
7. Other causes
Stopping or missing estrogens or oral contraceptives, stress, weight gain or loss, diet change, displaced intra uterine device, vagina injury, taking anticoagulant medications, etc.(5)
H.3. Prevention
1. Lose weight
Accumulation of fat in obese women can cause the increased risk of breakthrough bleeding due to ongoing production of estrogen.
2. Smoking
Smoking can interfere with menstrual control of oral contraceptive that can lead to breakthrough bleeding.
3. Reduce intake of enzyme inducers
4. Mifepristone
in the study to determine if mifepristone would decrease BTB in new starters of DMPA.
Twenty regularly cycling women who were new starters of DMPA were
randomized to receive 50 mg of mifepristone or placebo every 2 weeks for
24 weeks, researchers at the University of Southern California Keck School of Medicine, showed that percent days of BTB and number of cycles with
bleeding intervals > or =8 and > or =14 days were evaluated using daily
bleeding
diaries. Ovulation was determined by measuring thrice-weekly urinary
metabolites of estrogen and progesterone. Endometrial concentrations of
ER and PR were determined by immunohistochemistry. Mifepristone
significantly decreased the percent days of BTB and the number of cycles
with prolonged
bleeding
intervals when compared to placebo. No subject ovulated in either
group. ER immunostaining increased and PR immunostaining decreased after
mifepristone treatment. In conclusion, a 50 mg dose of mifepristone
taken every 2 weeks decreases the incidence of BTB in new starters of
DMPA. This effect may be due to modulation of endometrial estrogen and
progesterone receptors(6).
5. Etc.
H.3. Treatment and Management
1. Ongoing study
In the study of to evaluate doxycycline, a common antibiotic used to
treat infections and acne, as a possible treatment in preventing or
stopping unexpected menstrual bleeding in women, tf the study shows the drug is successful in stopping "breakthrough
bleeding," more women may turn to new continuous contraception options –
options that allow women to effectively stop menstrual bleeding, said
study investigator
Bliss Kaneshiro, M.D.,instructor in obstetrics and gynecology, OHSU School of Medicine(7).
Treatment and Management depening to the unlined causes, include
2. Excessive thick uterine lining (edometrium)
First, certain tests must be taken to rule out the cause of endometrial cancer(8). The excessive thicken endometrium may be as a result of estrogenic stimulation, wrong use of oral contraceptives, medication such tamoxifen, obese cause of excess estrogen due to fat, etc.
3.
Oral contraceptives(9)
If the breakthrough breeding is a result of the use of oral contraceptive, some researchers suggested
a. Missed pills, late pills, irregular taking. Probably the commonest cause of breakthrough bleeding
b. Breakthrough bleeding is more common in the first six months and will often settle.
c. Infectous diseases, especially chlamydia which not infrequently presents with a history of abnormal bleeding.
d. Drugs, especially enzyme inducers which increase the metabolic transformation
of the hormones as they pass through the liver thereby decreasing contraceptive blood levels.
e. Gastrointestinal upsets are well recognised as a cause of breakthrough bleeding due to impairment of absorption.
g. Some foods are enzyme inducers
h. The formulation may need changing but think of this last rather than first. Breakthrough bleeding is more common with the low oestrogen pills but may settle if given time. A triphasic formulation will often give good cycle control. Try changing the type of progestogen.
4.
Amenorrhea
If breakthrough is a result of medication-induced Amenorrhea, then taking off medication,
normal menstruation resumes in the cycle after they are discontinued.
5. Hormonal fluctuations
In this practice guideline, the management guidelines are limited to the treatment of
bleeding from the endometrium. In most cases
bleeding caused by
hormonal fluctuations
is self-limiting. However, symptomatic treatment with progestogens or
sub-50 oral contraceptives is possible. NSAIDs taken during the first
three days of menstruation are the second-choice treatment in women with
excessive
bleeding. Tranexamic acid or a levonorgestrel-releasing IUD are other possibilities. (10)
5. Progestin treatment
Clinicians routinely prescribe progestins along with estrogens during
menopausal hormone therapy (HT) to block estrogen-dependent endometrial
proliferation.
Breakthrough bleeding
(BTB) can negate the utility of this treatment. Because progestin
antagonists also inhibit estrogen-dependent endometrial proliferation in
women and macaques, we used a menopausal macaque model to determine
whether a potent progestin antagonist (ZK 230 211, Schering AG; ZK)
combined with estrogen would provide a novel mode of HT(11)
Sources
(1)
http://www.merriam-webster.com/medical/breakthrough%20bleeding
(2)
http://www.ncbi.nlm.nih.gov/pubmed/22383980
(3)
http://www.ncbi.nlm.nih.gov/pubmed/1533675
(4)
http://www.ncbi.nlm.nih.gov/pubmed/11084172
(5)
http://www.targetwoman.com/articles/breakthrough-bleeding.html
(6)
http://www.ncbi.nlm.nih.gov/pubmed/14668006
(7)
http://www.ohsu.edu/xd/about/news_events/news/2007-news-archive/08-27-drug-may-hold-key-to-pre.cfm
(8)
http://medicaladvisorjournals.blogspot.ca/2011/06/cancers-from-b-to-t-most-common-types_05.html.
(9)
http://www.rnzcgp.org.nz/assets/documents/Publications/Archive-NZFP/Dec-2002-NZFP-Vol-29-No-6/Sparrow-December-02.pdf
(10)
http://www.ncbi.nlm.nih.gov/pubmed/12467159
(11)
http://www.ncbi.nlm.nih.gov/pubmed/16936297
I. Ovarian hemorrhage
Approximately 4% of women are admitted to hospitals because of
ovarian cyst rupture,
hemorrhage, or torsion.
In the a study of
Ovarian hemorrhage
after transvaginal ultrasonographically guided oocyte aspiration: a
potentially catastrophic and not so rare complication among lean
patients with polycystic ovary syndrome, researchers at the Department of Obstetrics and Gynecology, Shaare Zedek Medical Center found that although acute
hemorrhage is a rare event after TVOA, lean patients with PCOS specifically are at much higher risk for this complication(1).
Others report of a case of an 18-year-old female with EBV-associated ITP, who developed
a severe intra-abdominal bleed secondary to a hemorrhagic
ovarian cyst. Females in this age group are in their early childbearing years and
present a unique set of possible hemorrhagic complications not seen in
younger patients(2).
Please check the following article for more information of ovarian bleeding
1. Ovarian Cysts In Conventional Medicine Perspective
2. Ovarian Cysts In Traditional Chinese Medicine Perspective
3. Endometriomas - Chocolate Cysts - In Conventional Medicine Perspective
4. Endometriomas - Chocolate Cysts - In Traditional Chinese Medicine
Sources
(1)
http://www.ncbi.nlm.nih.gov/pubmed/19064264
(2)
http://www.ncbi.nlm.nih.gov/pubmed/17279009
J. Upper gastrointestinal bleeding
Upper gastrointestinal bleeding (UGIB) is defined as hemorrhaging derived from a source proximal to the ligament of Treitz. It is life threatening and considered as medical emergency, which is followed by high mortality rate, ranging from 6 to 15% in spite of modern diagnostic methods and treatment.
J.1. Causes and risk factors
1. Causes
1.1. Esophageal causes of Upper gastrointestinal bleeding
Espophagus or gullet, an organ in vertebrates, is the tube that lead foods from the pharynx to the stomach.
a. Esophageal varices
In the study to investigate the effects of splenectomy and ligature of the left
gastric vein on risk factors for
bleeding of esophagogastric
varices in patients with schistosomiasis mansoni, hepatosplenic form, with a history of
upper gastrointestinal bleeding, showed that the variceal pressure has fallen from 22.3+/-2.6 mmHg before surgery to
16.0+/-3.0 mmHg in the immediate postoperative period (p<0.001),
reaching 13.3+/- 2.6 mmHg in the sixth month of follow-up. A significant
reduction of the frequency of the parameters associated with a greater
risk of
hemorrhage was observed between the preoperative period and six-month follow-up, when the proportion of large
esophageal varices (p<0.05),
varices extending to the
upper esophagus (p<0.05), bluish
varices (p<0.01),
varices with red signs (p<0.01) and gastropathy (p<0.05) decreased(1)
b. Esophagitis
there is a report of a case of recurrent, severe
upper gastrointestinal bleeding due to hemorrhagic candidal
esophagitis
in a man with renal failure is described. Dysphagia, odynophagia, and
retrosternal chest discomfort were all absent. Oral thrush was present
only at the outset. Standard therapy for massive
bleeding with blood products alone was not successful. Intravenous amphotericin eventually resulted in resolution, according to the study by University of Manitoba, Canada(2).
c. Esophageal cancer
Esophageal cancer is not very uncommon and caused by malignant of the
esophagus due to abnormal cell growth as a result of the DNA
alternation of the cells that line the upper part of the esophagus or
glandular cells that are present at the lower part of the esophagus
that connected with the stomach.
The esophageal cancer tend to
spread if it left untreated and starts from the lining of esophagus,
then later penetrate in the the wall of the esophagus and spread to the
lumph node around the bottom of the esophagus, stomach and the chest,
then to the distant parts of the body. for more information, please visit
http://medicaladvisorjournals.blogspot.ca/2011/06/cancers-from-b-to-t-most-common-types_07.html
d. Esophageal ulcers
there is a report of five cases in the
upper GI
tract due to insufflating large amounts of air through the endoscopes. All 5 patients needed an emergency
upper endoscopy for acute presumed
upper GI
bleeding. In two cases both
esophageal variceal
bleeding and
ulcer bleeding were detected; the fifth case presented with a
bleeding due to gastric cancer(3).
e. Other causes
Other causes of UGI
bleeding include
Dieulafoy's lesion, Mallory-Weiss syndrome, and portal hypertensive enteropathy. The most common non-variceal endoscopic findings reported in patients with lower
gastrointestinal bleeding are portal hypertensive colopathy and hemorrhoids(4).
1.2. Gastric causes of Upper gastrointestinal bleedinga
a. Gastric ulcer
There is a report iIn 16 patients (mean age, 59.4 years) with acute
bleeding ulcers (13
gastric ulcers, 2 duodenal ulcers, 1 malignant
ulcer), a metallic clip was placed via gastroscopy and this had been preceded by routine endoscopic treatment, according to the study of Chonbuk National University Medical School(5).
b. Gastric cancer
Bleeding from the upper
gastrointestinal system may be caused by
gastrointestinal stromal tumors of the stomach, which are mainly characterized by occult
bleeding, while profuse
bleeding rarely occurs accompanied by hemorrhagic shock.
Gastrointestinal stromal tumors of stomach are the most common mesenchimal tumors of the
gastrointestinal tract(1). For more information of Stomach Cancer/Gastric Cancer, please visit
http://medicaladvisorjournals.blogspot.ca/2011/06/cancers-from-b-to-t-most-common-types_30.html
c. Gastritis
In a material of 4560 panendoscopic investigations carried out in an endoscopy laboratory haemorrhages from the
upper gastrointestinal tract were found in 201 cases. In 49 cases the cause of blood loss was acute haemorrhagic
gastritis. Among them males accounted for 41% (mean age 35.6 years) and females for 59% (mean age 41.8 years)(6).
d. Gastric varices
Although most portal hypertensive bleeds result from the ruptured distal
esophageal varices, bleeding from other sources such
gastric varices, portal hypertensive gastropathy, and ectopic
varices can lead to clinically significant bleeding. Variceal bleeding typically presents as massive
gastrointestinal (GI) bleeding with hematemesis, melena or hematochezia(7).
e. Gastric antral vascular ectasia
Gastric antral vascular ectasia (GAVE) syndrome, also known as watermelon stomach is a significant cause of acute or chronic
gastrointestinal
blood loss in the elderly. is characterized endoscopically by
"watermelon stripes." Without cirrhosis, patients are 71% female,
average age 73, presenting with occult blood loss leading to
transfusion-dependent chronic iron-deficiency anemia, severe acute
upper gastrointestinal bleeding, and nondescript abdominal pain(8).
f. Dieulafoy's lesions
Dieulafoy's lesions are considered uncommon causes of
gastrointestinal bleeding and occur from pinpoint non-ulcerated arterial
lesions(9).
g. Etc.
1.3. Duodenal causes of Upper gastrointestinal bleeding
The
duodenum represents second place in frequency for the presence of diverticula in the digestive
tract after the colon. Duodenal diverticulum as a cause of
hemorrhage of the
upper gastrointestinal (GI)
tract has been described as an infrequent complication, although it must be considered in patients with digestive
hemorrhage without evident cause at the esophagogastric level(10).
1.4. Etc.
2. Risk factors
a. Medication
Medication such as aspirin,
NSAIDs, warfarin, corticosteroids and SSRIs are associated with increase risk of upper
gastrointestinal bleeding. In the study assess the impact of increased use of low-dose aspirin, other
non-steroidal anti-inflammatory drugs (
NSAIDs), warfarin, corticosteroids and selective serotonin re-uptake inhibitors (SSRIs) on the site and outcome of non-variceal
gastrointestinal (GI) bleeds, researchers at the Lund University, Lund, Sweden, found that aspirin, warfarin and SSRI users tended to suffer more severe GI bleeds
than non-users of these drugs. When comparing non-ulcer GI bleeds with
PUBs, aspirin (OR 0.56, 95% CI 0.38-0.82) was more strongly associated
with PUBs, whereas SSRIs (OR 3.71, 95% CI 1.39-12.9) and corticosteroids
(OR 2.8, 95% CI 1.28-6.82) were more associated with non-ulcer GI
bleeds after adjusting for age, gender and co-morbidity(11).
b. Acid reflux disease
Gastrointestinal
(GI) complaints are common among athletes with rates in the range of
30% to 70%. Both the intensity of sport and the type of sporting
activity have been shown to be contributing factors in the development
of GI symptoms. Three important factors have been postulated as
contributing to the pathophysiology of GI complaints in athletes:
mechanical forces, altered GI blood flow, and neuroendocrine changes. As
a result of those factors,
gastroesophageal reflux disease (GERD), nausea, vomiting, gastritis, peptic ulcers, GI
bleeding, or exercise-related transient abdominal pain (ETAP) may develop(12). For more information of
gastroesophageal reflux disease (GERD), please visit
http://medicaladvisorjournals.blogspot.ca/2011/09/gastroesophageal-reflux-disease-gerd.html
c. Age
Upper GI
bleeding was significantly correlated with age younger than 50 (P = .01) and male gender (P = .01; odds
ratio, 3.13)(13).
d. Coagulopathy
Coagulopathy
was prevalent in 16% of patients after nonvariceal
upper gastrointestinal bleeding (NVUGIB). and independently
associated with more than a fivefold increase in the odds of in-hospital
mortality. Wide variation in plasma use exists indicates clinical
uncertainty regarding optimal practice(14).
e. Etc.
J.2. Symptoms
Acccordfing to the study of a total of 124 patients were eligible for inclusion, 71 (57%) of whom were male. A total of 63 (51%) presented with
blood in stool and 53 (43%) with
bloody emesis; 8 (6%) had
blood
in
both emesis and stool. A total of 31 (25%) patients had a lower GI
bleed, 88 (70%) had an upper, and 5 (4%) had both upper and lower
bleeding sources. The mean BUN level was 24 mg/dL, the mean Cr level 1.03 mg/dL, and the mean BUN/Cr
ratio was 24. The mean hemoglobin (Hb) level was 11.3 g/dL, the mean Hct was 32 g/dL, and 51% required transfusion. Upper GI
bleeding was significantly correlated with age younger than 50 (P = .01) and male gender (P = .01; odds
ratio, 3.13)(15).
1. Blood vomiting looks like coffee grounds(15).
2. Blood in stool
3. Light head, Fatigue, Generalized weakness and fainting as a result of massive blood loss
4. Abdominal pain
5. Constipation
6. Diarrhea
7.
Gastroesophageal reflux disease (GERD)
8. Etc.
J.3. Diagnosis
According to the study by Georgia Health Sciences University,
Rapid assessment and resuscitation of
upper gastrointestinal bleeding should precede the diagnostic evaluation in unstable patients with severe
bleeding. Risk stratification is based on
clinical assessment and endoscopic findings. Early
upper endoscopy (within 24 hours of presentation) is recommended in most patients because it confirms the
diagnosis
and allows for
targeted endoscopic treatment, including epinephrine
injection, thermocoagulation, application of clips, and banding.
Endoscopic therapy results in reduced morbidity, hospital stays, risk of
recurrent bleeding,
and need for surgery. Although administration of
proton pump inhibitors
does not decrease mortality, risk of rebleeding, or need for
surgery,
it
reduces stigmata of recent hemorrhage
and the need for endoscopic therapy(16).
J.4. Prevention
1. Reduce stress
Stress-damage of
upper gastro-intestinal
tract (GIT) mucous membrane and gastro-intestinal
hemorrhage
(GIH)(17).
2. Cardiac surgery
GI
bleeding events occurred approximately 10 days after cardiac surgery in patients with a complicated postoperative course. Improving the heart function is the best way to reduced risk of
Upper gastrointestinal bleeding(18).
3. Drugs, alcohol and smoking
Chronic moderate alcohol consumption by itself does not seem to increase
the liability to peptic ulceration. With highly concentrated alcoholic
beverages, gastric
bleeding
from acute lesions may, however, be occasionally precipitated under
certain circumstances, such as when unbuffered ASA is taken
concomitantly.
Smoking
of cigarettes is associated, and perhaps causally related, with an
increased incidence of gastric and duodenal ulcerations, impaired ulcer
healing, and more frequent ulcer recurrences(19).
4. Avoid prolonged period intake of aspirin and medication which can induce Upper gastrointestinal bleeding (UGIB), such as Ibuprofen (Motrin, Advil)Naproxen (Anaprox, Naprosyn, Aleve)Ketoprofen (Orudis).
5. No extreme exercise
Gastrointestinal
(GI) complaints are common among athletes with rates in the range of
30% to 70%. Both the intensity of sport and the type of sporting
activity have been shown to be contributing factors in the development
of GI symptoms. Three important factors have been postulated as
contributing to the pathophysiology of GI complaints in athletes:
mechanical forces, altered GI blood flow, and neuroendocrine changes. As
a result of those factors,
gastroesophageal reflux disease (GERD), nausea, vomiting, gastritis, peptic ulcers, GI
bleeding, or exercise-related transient abdominal pain (ETAP) may develop(20).
6. Etc.
J.5. Treatments
Some researchers suggested that despite successful endoscopic
therapy, rebleeding can occur in 10 to 20 percent of patients; a second
attempt at endoscopic therapy is recommended in these patients.
Arteriography with embolization or surgery may be needed if there is
persistent and severe
bleeding(16). Others indicated that Pre-endoscopic management (including use of scoring scales, nasogastric
tube placement and blood pressure stabilization) is crucial for triage
and optimal resuscitation of patients, and should include a
multidisciplinary approach at an early stage. Unless the patient has
specific
comorbidities, transfusion should only be considered if their
hemoglobin level is ≤70 g/l.
Endoscopic therapy, the cornerstone of
therapeutic management of high-risk lesions, should not be delayed for
more than 24 h following admission. Several endoscopic techniques,
mostly using
clips or thermal methods, are available and new approaches
are emerging. When
endoscopy fails, surgery or arterial embolization
should be considered. Although the efficacy of prokinetics and high-dose
intravenous PPI prior to endoscopy is controversial, the use of an
intravenous PPI following endoscopy is strongly recommended.
Antiplatelet therapy should be suspended and resumed in 3-5 days.
Finally, all patients should be tested for Helicobacter pylori by
serology in the acute setting(21).
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http://www.ncbi.nlm.nih.gov/pubmed/8202782
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http://www.ncbi.nlm.nih.gov/pubmed/22649332
(4)
http://www.ncbi.nlm.nih.gov/pubmed/22661272
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http://www.ncbi.nlm.nih.gov/pubmed/21852908
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http://www.ncbi.nlm.nih.gov/pubmed/2623868
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http://www.ncbi.nlm.nih.gov/pubmed/20514835
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http://www.ncbi.nlm.nih.gov/pubmed/22534226
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http://www.ncbi.nlm.nih.gov/pubmed/22720275
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(1)
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