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Diseases » Hemorrhage » Diagnosis

Diagnosis of Hemorrhage

Hemorrhage Diagnosis: Book Excerpts

Diagnosis of Hemorrhage: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Hemorrhage:

Diagnostic Tests for Hemorrhage: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Hemorrhage.

BLEEDING GUMS: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

Are there abnormalities on examination of the teeth or gums? The gums may be swollen, as in phenytoin use and early scurvy, and bleed on slight pressure, as in pyorrhea or other conditions. There may be ulceration of the tongue, gums, and buccal mucosa. There may be an isolated dental caries that is causing bleeding. Excessive tartar may be noted on the teeth.
Is there an enlarged spleen or a systemic rash? The presence of an enlarged spleen should bring to mind Hodgkin's disease, leukemia, lupus erythematosus, thrombocytopenia purpura, and aplastic anemia. A systemic rash that is due to petechiae is common in any disorder that might cause thrombocytopenia.
Is there a positive Rumpel-Leede test? This would test for capillary fragility, and it may be positive in scurvy, thrombocytopenia purpura, leukemia, and other disorders that depress the platelet count. It will also be positive in disorders of platelet function such as von Willebrand's disease.

DIAGNOSTIC WORKUP

A CBC, sedimentation rate, chemistry panel, ANA titer, and coagulation profile are basic studies that need to be done. If these are negative, referral to a dentist or periodontist would be appropriate. X-rays of the teeth need to be done to look for dental caries, abscesses, and pyorrhea. X-rays of the teeth will also help identify scurvy. A plasma or platelet ascorbic acid level needs to be done if scurvy is suspected. If syphilis is suspected, a VDRL test needs to be done.

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PURPURA AND ABNORMAL BLEEDING: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

Is there a petechial rash? The presence of a petechial rash suggests either a thrombocytopenic purpura, which may be idiopathic or secondary to leukemia, aplastic anemia, collagen disease, or drugs. In addition, petechiae may suggest platelet dysfunction, in which case the platelet count will be normal, or vasculitis, such as from collagen diseases, hereditary telangiectasia, scurvy, or drugs.
Is there ecchymosis or bruises? The presence of ecchymosis or bruises would suggest hemophilia, Christmas disease, or other major coagulation defects, but it may also be related to platelet disorders or disseminated intravascular coagulation.
If there is a petechial rash, is the platelet count normal? The presence of a normal platelet count would suggest either thrombocytopathy or vasculitis.
Is there significant mucosal bleeding? The presence of mucosal bleeding along with ecchymosis and bruises suggests platelet disorders or disseminated intravascular coagulation.

DIAGNOSTIC WORKUP

If a coagulation disorder is suspected, consult a hematologist first. Routine diagnostic studies include a CBC, platelet count, sedimentation rate, blood smear for red cell morphology, urinalysis, chemistry panel, coagulation profile, rheumatoid arthritis factor, ANA test, serum protein electrophoresis, VDRL test, EKG, chest x-ray, and flat plate of the abdomen. The coagulation profile should include a platelet count, a bleeding time, a coagulation time, a partial thromboplastin time, and a prothrombin time.

If there is fever, blood cultures should be done. A bone marrow examination and bone marrow culture may be useful. If disseminated intravascular coagulation is suspected, a fibrinogen assay and estimation of fibrin degradation products should be done. Platelet function may be assessed by clot retraction tests. Spleen and liver scans and bone scans may be needed. A CT scan of the abdomen and pelvis may also be necessary. Skin, muscle, and even kidney biopsies are often done to complete the workup.

It can be seen from the above array of diagnostic tests that a hematologist should be consulted at the outset. Various forms of vasculitis may be confirmed by skin or muscle biopsy.

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

RECTAL BLEEDING: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

Is it severe? The presence of severe rectal bleeding would suggest ulcerative colitis, amebic dysentery, bacillary dysentery, intussusception, mesenteric thrombosis or embolism, diverticulitis, ischemic colitis, and coagulation disorders.
Is there diarrhea and/or mucus? The presence of diarrhea with or without mucus would suggest ulcerative colitis, amebic dysentery, or bacillary dysentery.
Are there signs of intestinal obstruction? The presence of signs of intestinal obstruction would suggest intussusception, mesenteric thrombosis, or embolism.
If the bleeding is mild, is the bleeding mixed well with the stools? Rectal bleeding that is mixed well with the stools suggests carcinoma of the colon, ulcerative colitis, Crohn's disease, Meckel's diverticulum, diverticulitis, and coagulation disorder.
Are there painful bowel movements? The presence of painful bowel movements, especially with bright red bleeding, would suggest anal fissure or thrombosed hemorrhoid.
Is there a rectal mass? The presence of a rectal mass would suggest a polyp, carcinoma, or internal hemorrhoids.

DIAGNOSTIC WORKUP

Most cases can be diagnosed by anoscopy, sigmoidoscopy, and a barium enema. A stool culture and examination for ovum and parasites should also be done. If the diagnosis is uncertain after these studies, referral to a gastroenterologist should be done for colonoscopy and other diagnostic studies. The gastroenterologist may order angiography or small intestinal enteroscopy as well as radioisotope studies.

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Abnormal Uterine Bleeding: Differential Diagnosis
(In a Page: Signs and Symptoms)

Endometrial hyperplasia
–Endogenous estrogen excess (e.g., obesity, tumor)
–Exogenous estrogen
–DUB is a diagnosis of exclusion (usually not cyclic, occurs irregularly throughout the menstrual cycle)
Polycystic ovarian syndrome
Hypo- or hyperthyroidism

Endometrial atrophy
–Caused by long-term progestin or oral contraceptive use
Anatomic or structural lesions
–Uterine leiomyoma (fibroids)
–Foreign body (often intrauterine device)
–Cervical or uterine polyps
Pelvic infection (cervicitis, pelvic inflammatory disease)
Hypothalamic lesion
Hyperprolactinemia
Medications (e.g., exogenous estrogen, phenothiazines, reserpine)
Coagulation disorders
–Platelet dysfunction: Thrombocytopenia, leukemia, medications (e.g., aspirin, NSAIDs)
–Clotting factor abnormality: Von Willebrand's disease, hemophilia, hepatic or renal disease, anticoagulant use
- Complications of pregnancy
  –Spontaneous abortion (miscarriage)
  –Ectopic pregnancy
  –Placenta previa
  –Placental abruption
- CT scan may be helpful if malignancy is suspected
- Hysteroscopy for evaluation of endometrium and uterine cavity
- Diagnostic dilatation and curettage is more invasive but offers more information than endometrial biopsy

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Source: In a Page: Signs and Symptoms, 2004

Bleeding (Excessive): Differential Diagnosis
(In a Page: Signs and Symptoms)

Drugs (e.g., aspirin, heparin, warfarin, alcohol, chemotherapy)
Senile purpura
Uremia
Liver disease
HIV
–Platelets decrease in number due to infection of megakaryocytes
Severe vitamin K deficiency
DIC
HSP
Von Willebrand's disease
Hemophilia
ITP
Heparin-induced thrombocytopenia
Myelodysplasia
TTP-HUS
Leukemia
Hereditary hemorrhagic telangiectasia
Ehlers-Danlos syndrome
Bernard-Soulier syndrome
Arteriovenous malformation
Pancytopenia
Isolated factor deficiency

Workup and Diagnosis

History and physical exam
–Personal or family history of bleeding, including bleeding with minor trauma, medications, postsurgical bleeding, menorrhagia, tooth extractions
–Rectal exam and stool guaiac testing for occult GI bleeding
–Joint exam for hemarthrosis

Initial laboratory tests include CBC with peripheral smear, platelet count, PT/INR (evaluates extrinsic pathway—factors X, VII, V, II, I), PTT (evaluates intrinsic pathway—XII, XI, IX, VIII, V, II, I), thrombin time (measures ability of thrombin to transform fibrinogen in fibrin), bleeding time (evaluates platelet function and capillary integrity), and urinalysis (for hematuria)
Additional tests may be indicated
–Fibrinogen assay
–Urea clot lysis test (evaluates factor XIII deficiency)
–Mixing studies (determines the presence of an anticoagulant in the blood)
–Specific factor assays
–Platelet adhesion and aggregation tests (to evaluate platelet function)
–Bone marrow aspirate (to evaluate platelet production and rule out leukemia)
Hematology consultation is often indicated

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Source: In a Page: Signs and Symptoms, 2004

GI Bleeding - Hematemesis: Differential Diagnosis
(In a Page: Signs and Symptoms)

Peptic ulcer disease is the most common etiology of upper GI bleeding
–Increased risk with NSAID, steroid, or alcohol use; smoking, stress (e.g., ICU and trauma patients), or infections (Helicobacter pylori, CMV, herpes simplex virus)
Nasopharyngeal or oropharyngeal sources of bleeding
Esophageal etiologies
–Esophageal varices (common in alcoholics and cirrhotic patients)
–Erosive esophagitis: Infectious (e.g., Candida, HSV, CMV), corrosive ingestion, or pill-induced
–Esophageal or gastric carcinoma
–Esophageal or gastric polyps
Gastric etiologies
–Gastric ulcer
–Gastritis
–Arteriovenous malformations: Osler-Weber-Rendu syndrome (cutaneous telangectasias, recurrent nosebleeds), idiopathic angiomas, radiation-induced telangectasias, blue rubber bleb nevus syndrome
–Mallory-Weiss tear secondary to repetitive vomiting
–Dieulafoy's lesion: Erosion of the mucosa overlying an artery in the stomach causes necrosis of the arterial wall and resultant hemorrhage
–Gastric varices: Secondary to splenic vein thrombosis
–Benign or malignant tumors
Duodenal etiologies
–Duodenal ulcer
–Erosion of a pancreatic tumor into the duodenum
–Aortoenteric fistula: Must be suspected in any patient with a known aortic graft (e.g., prior AAA repair or occlusive aortic disease)
Systemic etiologies
–Coagulopathies (e.g., hemophilia)
–Thrombocytopenia
–Anticoagulation therapy (e.g., warfarin)
–Hereditary hemorrhagic telangiectasia
–Leukemia
–Connective tissue disease

Workup and Diagnosis

Evaluate the severity of bleeding (e.g., signs of shock, orthostatic hypotension, decreased hematocrit) and begin immediate resuscitation if necessary

Identify the source of bleeding
–Nasogastric tube insertion to verify upper GI bleeding
–Upper GI endoscopy (EGD) is diagnostic in most cases (identifies the source of bleeding in 90% of patients) and may be therapeutic
–Angiography (radionuclide or conventional) is indicated for severe bleeds, if endoscopy is not available, or if endoscopy is inconclusive
–If patient has a known aortic graft (prior aneurysm repair or aortic occlusive disease), a high index of suspicion for an aortoenteric fistula
Initial labs should include CBC, coagulation workup (PT/PTT/INR, bleeding time, platelet count), glucose, electrolytes, BUN/creatinine, calcium, liver function tests, and toxicology screen (e.g., for alcohol)
–Elevated BUN/creatinine ratio suggests upper GI bleed
–Abnormal prothrombin time suggests coagulopathy
–Serial hemoglobin/hematocrit measurements are necessary as they may be initially high until volume is replaced; then may decrease

ECG may be indicated to rule out cardiac ischemia secondary to severe anemia, especially in patients with known diabetes and/or coronary heart disease

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Source: In a Page: Signs and Symptoms, 2004

GI Bleeding - Melena & Hematochezia: Differential Diagnosis
(In a Page: Signs and Symptoms)

Anatomic lesions
–Diverticular bleeding causes 30–50% of all cases of massive rectal bleeding; associated with mild, crampy pain, but can be painless; not associated with diverticulitis
–Meckel's diverticulum
Vascular lesions
–Angiodysplasia (arteriovenous malformation): Most frequent cause in older patients; bleeding tends to be episodic and self-limited; painless; increased risk with increased age
Neoplastic lesions
–Colon cancer or polyps: Causes 10% of cases of lower GI bleeding in patients >50 years; generally low-grade, recurrent bleeding
–Rectal cancer
–Small bowel tumors
Inflammatory lesions
–Colitis/ulcers (e.g., inflammatory bowel disease, infectious colitis, ischemic colitis, radiation colitis)
–Ischemic colitis generally presents with abdominal pain
–Ulcerative colitis more associated with gross rectal bleeding
–Crohn's disease more commonly associated with diffuse crampy abdominal pain, whereas ulcerative colitis is more localized to left lower quadrant
Anorectal lesions
–Hemorrhoids are the most common cause of rectal bleeding in patients younger than 50 years old; usually painless bleeding
–Fissures
–Polyps
–Idiopathic rectal ulcers

Aortoenteric fistula: Must be suspected in any patient with a known aortic graft (e.g., prior aortic aneurysm repair or occlusive aortic disease)
Idiopathic in up to 15% of cases
Upper GI bleeding
Systemic bleeding disorders (e.g., hemophilia, excessive anticoagulation, thrombocytopenia)

Workup and Diagnosis

Evaluate the severity of bleeding (e.g., signs of shock, orthostatic hypotension, decreased hematocrit)—if impending shock or exsanguination, emergent resuscitation (see below) and surgical intervention are indicated
Determine the source of bleeding
–Rectal examination
–Rule out upper GI bleeding by nasogastric tube aspiration or upper GI endoscopy
–Abdominal X-ray to rule out perforation or obstruction (before initiating colonoscopy)
–Colonoscopy is usually diagnostic for the bleeding source
–Angiography is used for active, heavy bleeding and/or if colonoscopy is inconclusive
–Tagged RBC scan is helpful for Meckel's diverticula
- Initial labs should include CBC, coagulation workup (PT/PTT/INR, bleeding time, platelet count), glucose, electrolytes, BUN/creatinine, LFTs, albumin, toxicology screen (e.g., for alcohol), and stool ova/parasites culture
- ECG may be indicated to rule out cardiac ischemia secondary to severe anemia, especially in patients with known diabetes and/or CAD

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Source: In a Page: Signs and Symptoms, 2004

Retinal Hemorrhage: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

It is critical to realize that hemorrhages do not progress but represent altered structure, and as such may affect acuity
Nonaccidental trauma must be the first etiology considered
Pigmented lesions of the retina including choroidal nevi, congenital hypertrophy of the retinal pigment epithelium, retinal pigment epithelial hyperplasia
Diabetic retinopathy is characterized by dot/blot, flame, preretinal, vitreous hemorrhages
Hypertensive retinopathy is typically accompanied by signs of hypoxia, e.g., cotton wool spots and optic disc swelling
May be associated with any systemic vascular disease or collagen vascular disease (e.g., systemic lupus erythematosus)

Vein occlusion
–Occlusion of a central vein may involve the entire retina, occlusion of one branch vein involves a section of the retina

Peripheral retinal hemorrhaging may be associated with vascular insufficiency due to carotid stenosis
May be associated with optic disc swelling
Traumatic truncal injury may create intraretinal hemorrhages called Purtscher lesions
Intracranial hemorrhage may dissect forward to surround optic nerve (Terson phenomenon)
Blood dyscrasias, anemias, leukemias, sickle cell, ocular sarcoidosis, Behçet disease, Eales disease may cause retinopathy
If sudden loss of vision is associated, wet macular degeneration, macular hemorrhage of histoplasmosis, preretinal hemorrhage, or vitreous hemorrhage may be the etiology
Retinal vascular tumors, which may have an associated neurologic aneurysm
HIV retinopathy presents with hemorrhage as first sign but may progress to involve and destroy vision

Workup and Diagnosis

History
–Evaluate status of known systemic diseases; e.g., hypertension, diabetes
–Investigate for undiagnosed systemic disease: Hypertension, diabetes, carotid occlusion, cardiac anomalies, blood disorders, HIV

Physical exam
–Visual acuity: Acuity is compromised if the hemorrhage lies within the foveal area
–Pupillary evaluation: Look for Marcus Gunn pupil
–Extraocular muscle evaluation for diplopia (may be associated with diabetes)
–Confrontation visual fields are indicated in all cases
–Perform a dilated fundus evaluation
Labs
–CBC, differential, lipid profile, ANA, sickle cell, ACE, serum calcium

Studies
–Ultrasonography, fluorescein angiography, ocular CT may be performed in conjunction with an ophthalmology consultation
–If secondary to a retinal vascular tumor, orbital and brain imaging with and without contrast is indicated with a neurologic consultation

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Abnormal Vaginal Bleeding: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Dysfunctional uterine bleeding (DUB)
–Physiologic anovulation is normal for up to 2 years after menarche
–Androgen excess
–Functional ovarian hyperandrogenism, or polycystic ovary syndrome, is common in adolescence
–Estrogen excess
–Hyperprolactinemia
–Hypothyroidism
–Early premature ovarian failure

Luteal phase defects

Pregnancy disorders
–Spontaneous abortion (threatened, missed, incomplete)
–Molar pregnancy
–Ectopic pregnancy

True vaginal bleeding
–Trauma (including sexual abuse)
–Vaginal sarcoma (sarcoma botyroides)
–Foreign body (more common in the younger child)

Menorrhagia
–Idiopathic: Most common cause of menorrhagia in adolescents
–Coagulopathy/bleeding disorder (e.g., thrombocytopenia, von Willebrand disease, factor IX deficiency)
–Uterine polyp or neoplasm
- Hematuria mistaken for vaginal bleeding
  –Urethral prolapse
  –Urinary tract infection
- Excoriations due to pruritus
- Vulvovaginitis
  –Trichomonas
  –Chlamydia
  –Gonorrhea
  –Pinworms (rare)
- Cervical lesions
  –Cervical polyp
  –Hemangioma
  –Cervical friability
Workup and Diagnosis
- History
  –Age at onset of bleeding
  –Quantity, duration, and frequency of bleeding
  –Associated pain or discomfort
  –Age at onset of puberty
  –First day of last menstrual period
  –Other symptoms: Dysuria, symptoms of hypothyroidism (fatigue, cold intolerance, constipation), symptoms of hyperprolactinemia (headaches, nipple discharge/galactorrhea)
  –Sexual abuse; sexual activity
  –Family history of irregular periods/infertility
- Physical exam
  –Inspection of external genitalia (anatomy, evidence of trauma, source of bleeding)
  –Evidence of puberty (breast development, estrogenization of vaginal mucosa)
  –Signs of virilization (hirsutism)
  –Nipple discharge
  –Signs of hypothyroidism (bradycardia, dry skin, coarse hair, short stature, delayed reflexes)
- Labs
  –LH, FSH, estradiol (E2), hCG
  –T4, TSH, prolactin
  –Platelet count, PT, PTT, bleeding time, vWF
  –Urine analysis
- Pelvic US to detect ovarian and uterine abnormalities
- MRI of pituitary to detect abnormalities of the gland

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Source: In A Page: Pediatric Signs and Symptoms, 2007

BLEEDING UNDER THE SKIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The clinical approach to purpura involves taking a drug history and a good family history, and ordering appropriate coagulation studies, tourniquet testing, and other tests. Referral to a hematologist is wise in obscure cases.

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Source: Differential Diagnosis in Primary Care, 2007

RECTAL BLEEDING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Armed with a more comprehensive list of causes of rectal bleeding, the clinician is ready to eliminate some of them as he or she asks appropriate questions during the history and performs the examination with all the causes in mind. The diagnosis may be pinned down by the presence or absence of other symptoms and signs. The principal diagnostic procedures are stool cultures, stool examination for ova and parasites, proctoscopy, barium enema, and colonoscopy.

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Source: Differential Diagnosis in Primary Care, 2007

VAGINAL BLEEDING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

A careful vaginal examination with the patient fully relaxed is most important. A rectovaginal examination must be performed to palpate masses in the cul-de-sac. Any vaginal discharge must be cultured for gonococci and Chlamydia organisms to rule out PID. Any suspicious lesion of the vagina or cervix must be biopsied and a pap smear is performed. If the diagnosis is uncertain at this point, a gynecology consult is in order. A D & C or endometrial biopsy must be done if uterine carcinoma is suspected. In women of childbearing age, a routine pregnancy test should be done but if an ectopic pregnancy is suspected a serum β-hCG subunit pregnancy test will be more definitive. Ultrasonography will often determine if a pelvic mass is an ectopic pregnancy. Ultrasonography will also be helpful in diagnosing ovarian cysts and tumors, but a CT scan of the pelvis can be more definitive.

If pathologic causes of dysfunction uterine bleeding are excluded, normal cyclic bleeding may be reestablished by a course of cyclic estrogen and progesterone or progesterone alone (a “medical D & C”). If this unsuccessful, a surgical D & C is required.

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Source: Differential Diagnosis in Primary Care, 2007

Gum bleeding [Gingival bleeding]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If gum bleeding isn’t an emergency, obtain a history. Find out when the bleeding began. Has it been continuous or intermittent? Does it occur spontaneously or when the patient brushes his teeth or flosses? Have the patient show you the site of the bleeding, if possible.

Find out if the patient or any family members have bleeding tendencies; for example, ask about easy bruising and frequent nosebleeds. How much does the patient bleed after a tooth extraction? Does he have a history of liver or spleen disease? Next, check the patient’s dental history. Find out how often he brushes his teeth, flosses, and goes to the dentist and what kind of toothbrush and floss he uses. Has he seen a dentist recently? To evaluate nutritional status, have the patient describe his normal diet and alcohol intake. Finally, note the prescription and over-the-counter drugs he takes.

Next, perform a complete oral examination. If the patient wears dentures, have him remove them. Examine the gums to determine the site and amount of bleeding. Gums normally appear pink and rippled with their margins snugly against the teeth. Check for inflammation, pockets around the teeth, swelling, retraction, hypertrophy, discoloration, and gum hyperplasia. Note obvious decay, discoloration, foreign material such as food, and absence of teeth.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Vaginal bleeding, postmenopausal: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Determine the patient’s age and her age at menopause. Ask when she first noticed the abnormal bleeding. Then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her periods regular? If not, ask her to describe any menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had any children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient’s mother, and ask about a family history of gynecologic cancer. Determine if the patient has any associated symptoms and if she’s taking estrogen.

Observe the external genitalia, noting the character of any vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient’s breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Abnormal premenopausal bleeding: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

The typical clinical picture confirms abnormal premenopausal bleeding. Special tests identify the underlying cause:

❑ Serum hormone levels reflect adrenal, pituitary, or thyroid dysfunction.

❑ Urinary 17-ketosteroids reveal adrenal hyperplasia, hypopituitarism, or polycystic ovarian disease.

❑ Endometrial sampling rules out malignant tumors and should be performed in all patients with premenopausal bleeding who are older than age 35.

❑ Pelvic examination, Papanicolaou (Pap) test, and patient history rule out local or malignant causes.

❑ Complete blood count rules out anemia.

If testing rules out pelvic and hormonal causes of abnormal bleeding, a complete hematologic survey (including platelet count and bleeding time) is appropriate to determine clotting abnormalities.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Dysfunctional uterine bleeding: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Diagnostic studies must rule out other causes of excessive vaginal bleeding, such as organic, systemic, psychogenic, and endocrine causes, including certain cancers, polyps, incomplete abortion, pregnancy, and infection.

Confirming diagnosis Dilatation and curettage (D & C) and biopsy results confirm the diagnosis by revealing endometrial hyperplasia.

Hemoglobin levels and hematocrit determine the need for blood or iron replacement.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Hereditary hemorrhagic telangiectasia: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Diagnosis is based principally on an established familial pattern of bleeding disorders and on clinical evidence of telangiectasia and hemorrhage. Bone marrow aspiration demonstrating depleted iron stores confirms secondary iron deficiency anemia. Hypochromic, microcytic anemia is common; abnormal platelet function may also be found. Coagulation tests are essentially irrelevant, however, because hemorrhage in telangiectasia results from weakness in the vascular wall.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Postmenopausal bleeding: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Diagnostic evaluation of the patient with postmenopausal bleeding should include physical examination (especially pelvic examination), a detailed history, standard laboratory tests (such as complete blood count), and cytologic examination of smears from the cervix and the endocervical canal. An endometrial biopsy or dilatation and curettage (D & C) with hysteroscopy reveals pathologic findings in the endometrium.

Diagnosis must rule out underlying degenerative or systemic disease. For instance, evidence of elevated levels of endogenous estrogen may suggest an ovarian tumor. Before testing for estrogen levels, the patient must stop all sources of exogenous estrogen intake — including face and body creams that contain estrogen — to rule out excessive exogenous estrogen as a cause.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Gum bleeding [Gingival bleeding]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Find out if the patient or any family members have bleeding tendencies; for example, ask about easy bruising and frequent nosebleeds. How much does the patient bleed after a tooth extraction? Does he have a history of liver or spleen disease? Next, check the patient’s dental history. Find out how often he brushes his teeth, flosses, and goes to the dentist, and what kind of toothbrush and floss he uses. Has he seen a dentist recently? To evaluate nutritional status, have the patient describe his normal diet and intake of alcohol. Finally, note any prescription and over-the-counter drugs he takes.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Vaginal bleeding, postmenopausal: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Hematochezia [Rectal bleeding]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the hematochezia isn’t immediately life-threatening, ask the patient to fully describe the amount, color, and consistency of his bloody stools. (If possible, also inspect and characterize the stools yourself.) How long have the stools been bloody? Do they always look the same, or does the amount of blood seem to vary? Ask about associated signs and symptoms.

Next, explore the patient’s medical history, focusing on GI and coagulation disorders. Ask about the use of GI irritants, such as alcohol, aspirin, and other nonsteroidal anti-inflammatory drugs.

Begin the physical examination by checking for orthostatic hypotension, an early sign of shock. Take the patient’s blood pressure and pulse while he’s lying down, sitting, and standing. If systolic pressure decreases by 10 mm Hg or more, or pulse rate increases by 10 beats/minute or more when he changes position, suspect volume depletion and impending shock.

Examine the skin for petechiae or spider angiomas. Palpate the abdomen for tenderness, pain, or masses. Also, note lymphadenopathy. Finally, a digital rectal examination must be done to rule out rectal masses or hemorrhoids.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Gastrointestinal Bleeding: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Clinical history accurately points to the source of bleeding in only 40% of cases (3).

A. Upper GI bleeding. Hematemesis and melena are the most common presentations of acute upper GI bleeding. Important questions to ask: Is there a prior history of bleeding (60% rebleed from the same site) (3)? Is there any family history? Does the patient have any comorbid diseases (peptic ulcer disease, pancreatitis, cirrhosis, cancer)? Is the patient taking any medications (especially nonsteroidal antiinflammatory agents)? Does the patient use recreational drugs, cigarettes, or alcohol? What is the character of the pain? Peptic ulcer pain is epigastric, gnawing, rhythmic, and dull. GI cancers are associated with vague epigastric pain, dysphagia, or weight loss. Was there any retching (Mallory–Weiss tear)? Does the patient have a history of prior surgeries? Patients with a history of vascular grafting are at risk for aortoenteric fistulae, which is often associated with a “herald bleed.”

B. Lower GI bleeding. How old is the patient? Age is an important feature in discriminating the source of lower GI bleeding. Patients aged less than 50 years usually bleed from infectious causes, anorectal disease, or inflammatory bowel disease. For patients aged more than 50 years, diverticulosis, angiodysplasia, cancer, and ischemia are most common (4). Are there any associated symptoms? Diverticular disease presents as painless, high volume bleeding. Angiodysplasia and cancer present with symptoms of chronic blood loss (fatigue, dyspnea on exertion). Inflammatory bowel disease presents with bloody diarrhea, cramping, weight loss, and fever. A prior history of inflammatory bowel disease, cancer, or radiation to the abdomen is also important.

Physical examination

A. Vital signs. The single most important aspect of the initial physical examination is determining the patient’s hemodynamic stability. Unstable patients should be managed as trauma patients. Placement of a nasogastric (NG) tube is considered the “fifth vital sign” in patients with acute GI bleeding (2).

B. Focused physical examination. After ensuring hemodynamic stability, the initial physical examination should eliminate a nasal or oropharyngeal source of bleeding. Examine the skin and abdomen carefully for clues to an underlying cause. A rectal examination is mandatory.

1. Skin examination. Ecchymoses, petechiae, and varices should be noted. Conjunctival pallor is a sign of chronic anemia. Numerous mucosal telangiectasias can point to an underlying vascular abnormality.

2. Abdominal examination. Look for stigmata of chronic liver disease (hepatosplenomegaly, spider angiomata, ascites, palmar erythema, caput medusae, gynecomastia, and testicular atrophy) (Chapter 9.9).

3. Rectal examination. Rectal varices, hemorrhoids, and fissures should be noted.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Postmenopausal Bleeding: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Pattern of bleeding. Although the amount of bleeding is not helpful in identifying malignancy, it should be assessed to determine the likelihood of significant anemia or hypovolemia that may require intervention. Timing of bleeding may suggest its cause.

1. Specific relationship to medication courses or cycles suggests drug-induced bleeding.

2. Postcoital bleeding suggests an atrophic cause or cervical polyp.

3. Association with bowel movements or urination suggests a nongenital source.

B. Current medications. Any hormonal therapy, including estrogen, progesterone, tamoxifen, thyroid replacement, or corticosteroids, should be quantified and recorded.

1. Acyclic bleeding is common in the first 3 to 4 months on continuous estrogen–progestin therapy, and usually does not indicate pathology. Bleeding that is excessive, persists after months of therapy, or occurs after amenorrhea has been established on these regimens should be evaluated.

2. The rate of endometrial cancer in women on tamoxifen or unopposed estrogen is six to seven times the rate for untreated women. The frequency of endometrial polyps is also increased.

3. Exogenous corticosteroids and incorrect dosage of thyroid replacement can lead to menstrual irregularities and postmenopausal bleeding.

C. Past medical history. Nulliparity, early menarche, late menopause, and history of chronic anovulation are risk factors for endometrial hyperplasia and carcinoma. Obesity, hypertension, diabetes, and liver disease are commonly associated with estrogen excess, and can also increase risk (1). Past use of oral contraceptives is associated with decreased risk.

D. Family history. A strong family history of endometrial or colon cancer is a risk factor for endometrial cancer.

Physical examination

A. Vital signs. Blood pressure and pulse can indicate the degree and acuity of blood loss; orthostatic changes can be evidence of significant volume depletion. Fever suggests infection as a potential cause (Chapter 2.6).

B. Abdomen. Tenderness or guarding suggests an infectious or inflammatory cause. Palpation for suprapubic masses is necessary as part of the evaluation for malignant causes.

C. Pelvis. Examine external genitalia, vagina, and cervix for lesions or lacerations that could be the source of bleeding. The uterus and ovaries must be palpated to assess for enlargement, masses, and tenderness.

D. Rectum. Rectal examination and anoscopy may be warranted to rule out hemorrhoids or other intestinal source of bleeding (Chapter 9.11).

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Rectal Bleeding: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Initial history. The history is an important tool for risk stratification. Important questions to ask: What is the color of blood passed? Is the bowel movement associated with pain? How long has the bleeding occurred? Is there blood on toilet tissue versus mixed with stool, or dripping into the toilet bowel? Have there been prior episodes? Is abdominal pain, constipation, diarrhea, medication use, or weight loss present? What medications do you take? The only historical questions that have evidence-based data to support benign versus serious pathology are the presence of constipation, diarrhea, age less than 50 years, and bleeding longer than 2 months (1,2) (Chapters 9.3 and 9.4). These findings are associated with more benign causes. An exception to this is in the pediatric age group where bleeding in children can represent hereditary and anatomic anomalies (4).

B. Other questions that can help discriminate serious from benign causes are a change in bowel habit to persistent loose stools for more than 1 month, absence of perianal symptoms in the presence of rectal bleedings, first time rectal bleeding, and the appearance of dark red blood (3). These are especially likely to be associated with more serious causes.

Physical examination

Assess the patient’s weight, general condition, and vital signs. Orthostatic blood pressure changes with a drop of 10 mm Hg or an increase in heart rate of 10 beats/minute indicates a blood loss of at least 1,000 ml (20% of circulating blood volume) (5). It is important to perform an external anal inspection, (checking for external hemorrhoids, fissures), digital rectal examination (checking for a rectal mass, polyp or anal pain), abdominal examination (checking for tenderness or mass), and nasopharyngeal examination (checking for a bleeding source).

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Purpura/Petechiae/Excessive Bleeding: Differential Overview
(Field Guide to Bedside Diagnosis)

Purpura

❑Trauma

❑Senile purpura

❑Drugs

❑Vasculitis

❑Vitamin K deficiency

❑Psychogenic purpura

❑Cholesterol emboli

❑Warfarin necrosis

❑Scurvy

❑Thrombotic thrombocytopenic purpura

❑Henoch-Schonlein purpura

❑Amyloidosis

Petechiae

❑Autoimmune thrombocytopenia

❑Bacteremia

❑Hypersplenism

Excessive Bleeding

❑Over-anticoagulation

❑Thrombocytopenia

❑von Willebrand disease

❑Circulating anticoagulant

❑Disseminated intravascular coagulation

❑Hemophilia

Diagnostic Approach

A patient with a suspected bleeding disorder should be questioned about response to trauma, past bleeding problems, for example with surgery or dental extractions, history of transfusion, menstrual history and dietary habits. Absence of abnormal bleeding with surgery, significant trauma, or dental extractions makes an inherited bleeding disorder unlikely.

Petechiae are small capillary hemorrhages resulting from platelet or vascular abnormalities. Petechiae on the lower extremities or mucous membranes are usually caused by thrombocytopenia. Tender, elevated petechiae plus abnormalities in other organs suggests vasculitis. Platelet defect disorders produce petechiae and ecchymoses occurring immediately after local trauma. Bleeding is superficial, occurring in the skin, the mucous membranes, the nose, and the gastrointestinal and genitourinary tracts. Bleeding does not occur with normal platelets until the count falls to less than 50,000, and the threshold for important bleeding is 20,000. Oozing blood around catheters suggests DIC, vitamin K deficiency, or platelet abnormalities.

Large-area bruising occurs with vitamin-K–dependent factor deficiency, but not with hemophilia. Plasma protein disorders produce bleeding in deep tissues, such as joints, muscle, and retroperitoneum. The onset of such bleeding can be delayed for hours after trauma.

Palpable purpura is seen with autoimmune or infectious (e.g., meningococcemia, endocarditis) vasculitis. Infectious emboli have an irregular outline, whereas lesions of leukocytoclastic vasculitis are circular.

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Source: Field Guide to Bedside Diagnosis, 2007

Gastrointestinal Bleeding: Differential Overview
(Field Guide to Bedside Diagnosis)

Upper GI

❑ Peptic ulcer disease

❑ Gastritis

❑ Mallory-Weiss tear

❑ Esophageal varices

❑ Esophagitis

❑ Epistaxis

❑ Esophageal cancer

❑ Gastric cancer

Lower GI

❑ Infectious diarrhea

❑ Diverticular bleeding

❑ Hemorrhoids

❑ Anal fissure

❑ Inflammatory bowel disease

❑ Angiodysplasia

❑ Colon cancer

❑ Mesenteric ischemia

❑ Aortoenteric fistula

DIagnostic Approach

With overt bleeding, determining whether a source is proximal or distal to the ligament of Treitz is key to the further diagnostic evaluation. Hematemesis confirms an upper GI source, and suggests loss of more than a quarter of blood volume. Melena (black, tarry stool) also comes from an upper source unless the bleeding is brisk or large volume and transit is rapid. Melena without hematemesis usually results from a lesion distal to the pylorus (e.g., duodenal ulcer) or to slow bleeding. Tarry stools may be produced by as little as 100 mL of blood. Lower sources produce hematochezia (maroon or clots from the right colon and bright red from the left colon). A small amount of blood only on the toilet tissue nearly always comes from a bleeding hemorrhoid or fissure. Silver stool is said to arise from acholic stools combined with luminal bleeding in an ampullary cancer.

Determine the hemodynamic significance of the bleeding by looking for postural lightheadedness or changes in pulse or blood pressure. Early symptoms of thirst and lightheadedness occur with loss of more than 15% of intravascular volume. An orthostatic blood pressure drop of 10 mm Hg indicates a loss greater than or equal to 20% of volume. Shock with hypotension and pallor develops with 25% to 40% volume loss.

Stools may be falsely colored by ingestants such as bismuth subsalicylate, iron, licorice or charcoal, which turn it black, or beets, which turn it red. These stools are not sticky. A negative stool test for occult blood will usually resolve this.

Hemoccult screening detects blood loss down to 1 to 10 ml/day. Evaluation of a heme positive stool will reveal colon cancer in 5% to 14% of patients, and large adenomatous polyps in another 15% to 35%. Any single positive stool should be evaluated. Hemoccult screening reduces colon cancer mortality by 15% to 33%. An asymptomatic patient with a negative Hemoccult has only a 0.2% chance of having colon cancer (compared with 1.4% prevalence in this population). Using Hemoccult alone as a screening strategy will miss 50% to 60% of colon cancers.

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Source: Field Guide to Bedside Diagnosis, 2007

Vaginal Bleeding: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Ovulatory bleeding

❑ Anovulatory bleeding

❑ Uterine leiomyoma

❑ Dysfunctional bleeding

❑ Threatened abortion

❑ Cervical erosion or polyp

❑ Perimenopause

❑ Retained products of gestation

❑ Ectopic pregnancy

❑ Oral contraceptives

❑ Hyperandrogenism

❑ Cervical cancer

❑ Endometrial cancer

❑ Anticoagulation therapy

❑ Thrombocytopenia

❑ Hypothalamic-pituitary-gonadal immaturity

Diagnostic Approach

Passage of clots or inability to control bleeding with tampons is consistent with heavy flow (menorrhagia). Bleeding between normal cyclic menses is metrorrhagia. Remember to establish that bleeding is uterine and not from the rectum or urethra.

In adolescents, anovulation is the cause in 90% of cases of metrorrhagia, although pregnancy should be considered. An underlying bleeding diathesis is found in about 20% of adolescents with menorrhagia. In adult premenopausal women, pregnancy and malignancy are the most important considerations, although leiomyomas (fibroids) are the most common. In perimenopausal women, anovulatory cycles and progesterone deficiency with long periods of unopposed estrogen lead to endometrial hyperplasia and polyps. Bleeding in postmenopausal women should be thoroughly evaluated for endometrial cancer, which will be found in 10% of cases.

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Source: Field Guide to Bedside Diagnosis, 2007

Vaginal bleeding, postmenopausal: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Determine the patient’s age and her age at menopause. Ask when she first noticed the abnormal bleeding. Then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her menses regular? If not, ask her to describe any menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had any children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient’s mother, and ask about a family history of gynecologic cancer. Determine if the patient has any associated symptoms and if she’s taking estrogen.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Gum bleeding: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Find out if the patient or any family members have bleeding tendencies; for example, ask about easy bruising and frequent nosebleeds. How much does the patient bleed after a tooth extraction? Does he have a history of liver or spleen disease? Next, check the patient’s dental history. Find out how often he brushes his teeth, flosses, and goes to the dentist. Also ask the patient what kind of toothbrush and floss he uses. Has he seen a dentist recently? To evaluate nutritional status, have the patient describe his normal diet and intake of alcohol. Finally, note any prescription and over-the-counter drugs he takes.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Gastrointestinal Bleeding: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Upper Gastrointestinal Bleeding

Nose

See Chap.18, Epistaxis.

Mouth and Pharynx

Trauma orforeign body may produce bleeding in mouth or pharynx.

History and physical exam are usuallydiagnostic.

Esophagus

Esophagitis

May presentwith hematemesis and sometimes occult blood loss.

Gastroesophageal reflux and causticingestions are common causes. Less common cause is infection, whichusually occurs in immunocompromised individuals. Pathogens includeherpes simplex virus, adenoviruses, cytomegalovirus, VZV, and Candidaspecies.

Diagnosis of esophagitis may be confirmedby endoscopy and biopsy. These infections may be diagnosed by specificcultures.

Foreign Body

Foreignbody lodged in esophagus may cause difficulty swallowing, pain,and bleeding.

Chest radiography may show radiopaqueforeign body.

Endoscopy is definitive procedure forremoval.

Varices

Consequenceof portal hypertension.

Major causes of portal hypertensionare parenchymal liver disease and anatomic obstruction of portalvein or its major branches.

Acute painless GI bleeding that occasionallycan be massive is often presenting sign. Other findings may includevisible abdominal wall collateral vessels, splenomegaly, and ascites.Hepatomegaly usually indicates liver parenchymal disease, but acirrhotic liver may be small and shrunken.

Endoscopic exam visualizes varices.

Duplication

Usuallyinvolves lower esophagus and may cause dysphagia.

Large duplication also may cause respiratorydistress.

If duplication contains ectopic gastricmucosa, bleeding can occur.

Diagnosis can usually be made by chestCT with oral contrast.

Gastroesophageal Junction

Tears inmucosa at gastroesophageal junction can result from continued forceful vomitingand retching; condition is called Mallory-Weiss syndrome.

Bleeding is usually self-limited.

Endoscopy can confirm diagnosis.

Stomach

Gastritis

In neonates,gastritis may be due to perinatal asphyxia, septicemia, or hypotension, butoften it is unexplained.

In infancy and childhood, epigastricpain and vomiting are frequent findings with gastritis. Viral illnessand drugs (e.g., aspirin and NSAIDs) are predisposing factors.

In adolescence, chronic alcohol intakemay cause gastritis.

In any age group, causes of stressgastritis include head injury, burns, septicemia, and shock.

Gastric aspirate may contain materialresembling coffee grounds or bright red blood.

Ulcer

Gastriculcer may cause acute bleeding with hematemesis or melena.

Another presentation is finding bloodin stool associated with chronic blood loss and anemia.

See Chap.2, Abdominal Pain.

Duplication

Duplicationof stomach usually involves greater curvature near antrum or pylorus.

Neonates may have vomiting, abdominalmass, and abdominal distension.

Vomiting, intermittent abdominal pain,and GI bleeding may occur in childhood.

Abdominal U/S is usually diagnostic.

Vascular Malformation

Angiodysplasticlesions and arteriovenous malformations can occur in stomach and insmall and large intestine.

Any of these lesions can present withrecurrent painless upper or lower GI tract bleeding.

Endoscopy and angiography are bestavailable diagnostic tools.

Neoplasm

Gastricneoplasms are extremely rare in pediatric population, yet can causeGI bleeding.

Benign tumors include teratoma andleiomyoma, whereas malignant tumors include gastric carcinoma, lymphoma,and leiomyosarcoma.

Combination of abdominal U/S,CT, and endoscopy with biopsy are diagnostic.

Duodenum

In addition to conditions detailed below,varices and vascular malformations can cause GI bleeding.

Ulcer

Duodenalulcer can have similar presentation as gastric ulcer.

See Chap.2, Abdominal Pain.

Foreign Body

Occasionallysharp objects may pass from stomach into duodenum and cause bleeding.Swallowed foreign body may be held up in C loop of duodenum or atpoint of constriction (e.g., ligament of Treitz) and cause obstructivesymptoms and hematemesis.

Combination of plain abdominal radiography,abdominal U/S, and endoscopy is usually diagnostic.

Duplication

Tends tocompress first or second portions of duodenum, producing partialobstruction. Presence of ectopic gastric mucosa predisposes to GIbleeding.

Abdominal U/S is usually diagnostic.

Hemobilia

Most commoncause of bleeding into biliary tract in children is abdominal trauma withinjury to liver and biliary tree.

Abdominal U/S and CT are usefulin locating and defining extent of injury. Duodenal endoscopy mayshow blood oozing from ampulla. If this is negative, celiac angiographymay locate site of bleeding if brisk. If bleeding is slower, technetium-sulfurcolloid scan may detect bleeding.

Other

Swallowed Blood

Maternalblood can be swallowed during passage through birth canal or frombreast-feeding if nipples are cracked.

Apt test can determine whether RBCsare fetal or maternal in origin and can be performed on either NGaspirate or stool.

In this test, small amount of NG contents orstool is mixed with tap water (1 part stool:5 parts water).

After centrifugation, 1 mL of 0.25NNaOH is added to 5 mL of pink supernatant fluid; mixture is leftfor 5 mins.

Pink color signifies fetal Hgb, whereasbrownish yellow color signifies maternal Hgb.

Coagulopathy

Bruising,purpura, and bleeding from sites other than GI tract are clues topresence of systemic bleeding disorder.

See Chap.52, Purpura and Bleeding.

Hemorrhagic Disease of the Newborn (Vitamin K Deficiency)

Becauseneonates have low vitamin K stores, they often fail to develop effectivecoagulation function.

At 2–4 days of age, if vitaminK has not been given at birth, hematochezia, melena, or hematemesismay develop. Bleeding also may occur from other sites beside GItract.

Lack of vitamin K administration atbirth, normal platelet count, and reversal of prolonged prothrombintime (PT) and activated partial thromboplastin time (aPTT) withdecreased bleeding after vitamin K administration confirm diagnosis.

Every newborn should receive 0.5–1.0mg IM of vitamin K at birth so this problem can be prevented.

Disseminated Intravascular Coagulation

Predisposingcauses include bacterial meningitis, septicemia, severe hypoxia,necrotizing enterocolitis, and shock.

Patients are seriously ill and havediffuse bleeding from multiple sites from consumption of clottingfactors and destruction of platelets.

Certain lab findings help confirm diagnosis:low platelet count, fragmented RBCs on blood smear, prolonged PTand aPTT, low plasma fibrinogen, and increase in fibrin-split products.

Drugs

GI bleeding may occur with chronic ingestionof aspirin, which causes a defect in platelet aggregation and aprolonged bleeding time. Excessive use of NSAIDs and anticoagulantsalso may cause significant GI bleeding.

Lower Gastrointestinal Tract Bleeding

Intestine

Cow Milk/Soy Protein Sensitivity

Infantsoften present with diarrhea that contains blood. Practical way tomanage this problem is to eliminate cow milk or soy protein fromdiet and monitor for whether symptoms disappear.

See Chap.14, Diarrhea.

Necrotizing Enterocolitis

Common disorderin preterm infants that can occur in term infants. History of perinatalstress (asphyxia, hypotension, septicemia) often exists.

Clinical findings include poor feeding,lethargy, abdominal distension, bilious vomiting, and bloody orblood-streaked stools.

Abdominal radiography that shows gasin bowel wall or in portal venous system helps confirm diagnosis.

Infectious Colitis

Most frequentpathogens in infancy and childhood are Salmonella, Shigella, Campylobacter,and E. coli. Less common is infection with C. difficile and Y. enterocolitica.Most common pathogen associated with HUS is E. coli 0157:H7.

Usual presenting manifestations arefever and bloody diarrhea.

Positive stool culture is diagnostic,except for infection with C. difficile, for which toxin must beidentified.

Henoch-Schönlein Purpura

Lower GIbleeding from the small intestine or colon can be occult or obvious.Typical purpuric rash occurs on buttocks and lower legs.

See Chap.28, Hematuria.

Intussusception

Common causeof lower GI bleeding in children 2 mos–5 yrs of age.

Most common type is ileocolic, whichinvolves telescoping of distal ileum into ascending or transversecolon.

History of intermittent cramping abdominalpain is usually presenting symptom. Vomiting and bloody (currantjelly) stools also may occur. Abdominal mass may be palpable anywherein abdomen.

Abdominal radiography that shows leadingedge of intussusceptum outlined by air is diagnostic, but oftenradiographs are nonspecific. Air-contrast enema can be diagnosticas well as therapeutic. Contraindications to its use are free abdominalair, intestinal obstruction with fluid levels on abdominal radiography,and clinical peritonitis. With any of these findings, surgery shouldbe performed immediately.

Congenital Aganglionic Megacolon (Hirschsprung Disease)

Enterocolitismay occur as complication.

Most common manifestations are abdominaldistension, diarrhea that is often bloody, fever, and vomiting.

See Chap.9, Constipation, and Chap. 14, Diarrhea.

Meckel Diverticulum

Remnantof omphalomesenteric duct that is located in distal ileum.

Usually presents in infancy with painless,episodic, bright red rectal bleeding, which may be massive.

Most diverticula contain gastric mucosa,and technetium 99m–pertechnetate scan can be diagnostic.

False-positive scans are uncommon butsometimes occur with ulcer, hemangioma, or bowel duplication.

Laparoscopy or laparotomy may sometimesbe necessary to confirm diagnosis.

Volvulus with Malrotation

Usuallypresents with intestinal obstruction; however, lower GI bleedingalso can occur.

Abdominal radiography shows dilatedloops of bowel with air-fluid levels. Upper GI series is usuallyperformed; however, with suspected bowel infarction, contrast studiesare unnecessary, and surgery should be performed immediately.

Inflammatory Bowel Disease

Occult GIblood loss or obvious lower GI tract bleeding may occur. Chronicdiarrhea with lower GI bleeding and weight loss should suggest IBD.

Crohn disease and ulcerative colitisare types of IBD.

See Chap.14, Diarrhea.

Intestinal Polyps

Definedas protrusion of tissue above normal GI surface that can cause bleedingand occasionally intussusception.

Number and location of polyps, theirhistopathology, and family history of colorectal cancer helps determineproper management.

This section focuses on common polyposissyndromes in pediatric population.

Solitary Juvenile Polyps/Juvenile Intestinal Polyposis

Solitaryjuvenile polyps usually present with painless rectal bleeding oranal prolapse of polyp in children 2–10 yrs of age. Mostchildren have single polyp, which should be removed for histopathologicexam.

Children with ≥2 rectosigmoid polypsand family history of polyps should be suspected of having juvenileintestinal polyposis, which is transmitted as autosomal-dominanttrait.

Manypolyps occur in the colon, but they also may be found in small intestineand stomach.

Age of presentation is usually in school-agedchildren.

Clinical manifestations include abdominalpain, rectal bleeding, and anemia.

There is high incidence of colorectalneoplasia in individuals with this disorder.

Adenomatous Polyposis of Colon

Autosomal-dominantdisorder caused by mutations in adenomatous polyposis coli gene,whose locus has been mapped to chromosome 5q21-q22.

Characterized by premalignant adenomaslocated primarily in colon and rectum and less commonly in stomachand small intestine.

Onset is usually in adolescence, whenhundreds to thousands of adenomas may appear. Other manifestationsinclude osteomas (jaw, long bones), skin lesions (cysts, lipomas),and pigmented retinal lesions.

Diagnosis is confirmed by colonoscopyand biopsy.

Peutz-Jeghers Syndrome

Autosomal-dominantdisorder in which hamartomatous polyps occur primarily in smallintestine but also may be found in colon and stomach. Gene locushas been mapped to chromosome 19p13.3.

Besides GI bleeding, characteristicfeature is presence of hyperpigmentation, which is seen most commonlyon buccal mucosa and lips.

Upper and lower GI endoscopy and upperGI radiographic series should be performed.

These individuals are at increasedrisk for adenocarcinoma, especially of stomach, duodenum, and colon.

Benign Lymphoid Hyperplasia

Large aggregatesof lymphoid tissue occur in colon and rectum. Rectal bleeding and sometimesintermittent diarrhea occur.

Proctosigmoidoscopy, colonoscopy, andhistologic exam confirm diagnosis.

Duplication

May be foundin jejunum and ileum. Abdominal pain, partial intestinal obstruction, orGI bleeding can be presenting feature. Sometimes small bowel intussusceptionor volvulus occurs.

May also involve colon and rectum,but bleeding rarely occurs because colonic duplications rarely containgastric mucosa. Affected individuals may present with abdominalpain and partial intestinal obstruction or they may be asymptomatic.

Abdominal U/S is usually diagnostic,although abdominal CT may be useful in some cases.

Vascular Malformation

Althoughrare, angiodysplastic lesions and arteriovenous malformations cancause lower GI bleeding.

Diagnosis is usually made by angiography.

Neoplasm

GI tumorsare rare in children.

Hemangiomas can be found anywhere insmall or large intestine but usually involve sigmoid colon and rectum.Endoscopy is usually diagnostic.

Adenocarcinoma of colon usually appearsafter 10 yrs of age. Persistent vomiting, anorexia, weight loss,abdominal pain, and GI bleeding are common manifestations. Contrastenema and colonoscopy with biopsy are diagnostic.

Rectum and Anus

Anal Fissure

Common causeof blood-streaked stools in neonates and young infants. Common causesare trauma from passage of hard stool and frequent use of rectalthermometer.

Stretching anal skin enables fissureto be visualized.

Trauma

Any foreignbody placed in rectum may cause trauma and bleeding.

History and physical exam are usuallydiagnostic, but proctoscopy may be needed in some cases. Plain radiographsof lower abdomen and pelvis can demonstrate radiopaque objects.

Sexual Abuse

Rectal trauma and bleeding may occur as resultof sexual abuse. History, physical exam, and proctoscopy are diagnostic.

Hemorrhoids

Defined as thrombosed collections of bloodvessels in anal area, which are uncommon in infancy and childhood.Usual cause is chronic constipation.

Other

Other causes of GI bleeding are swallowedblood, coagulopathy, and drugs.

Factitious Bleeding

Factitioushematemesis, hematochezia, or melena may be seen with various foods, medications,and artificial food colorings.

Commercial dyes no. 2 and no. 3 foundin breakfast cereals and fruit drinks may produce reddish colorof vomitus or stool.

Certain substances produce blackishcolor of stools: iron preparations, licorice, blueberries, beets,lead, charcoal, and bismuth.

In Munchausen syndrome by proxy, emesisor stool may be contaminated with blood that is not the child's.

Diagnostic Approach

Determination of Gastrointestinal Bleeding

Determinewhether reddish color of vomitus or stool is blood (e.g., raspberries,beets, and food colorings can give reddish color).

Gastroccult (Smith Kline Diagnostics,San Jose, CA) test may be used to detect presence of blood in vomitusor gastric aspirate. Hemoccult test can be used to confirm presenceof blood in stool.

Severity of Bleeding

If GI bleedingis obvious, most important task is to determine severity.

Important to quantitate amount of bleeding:1–2 drops, 1 teaspoonful, 1 cupful, or massive bleedingwith clot formation. Passage of clots via rectum or vomiting of >1cupful of bright red blood is indicative of significant bleeding.

In such cases, first note vital signsand perform any necessary resuscitation.

Immediate fluid replacement is requiredto stabilize BP.

Site of the Bleeding

Determinethe site of bleeding—whether it is from the upper or lowertract or both. Blood from nose or mouth can be swallowed and subsequentlyvomited or passed in stool. Retching from vomiting also can producesome blood-stained vomitus but is rarely severe.

Except in these instances, NG tubeshould be placed to document level and rate of bleeding.

Gastric aspirate that is positive forblood is highly specific for upper tract bleeding. Negative aspiratesuggests lower tract bleeding but does not totally preclude uppertract bleeding, especially from duodenum.

Specific Diagnosis

Importantfactors to consider in diagnosis are

Age

Clinical findings (e.g., vomiting,diarrhea, fever, constipation, abdominal pain, hepatomegaly, splenomegaly,abdominal distension, weight loss, and jaundice)

History of aspirin, NSAID, or alcoholingestion

Presence of known diseases (e.g., IBDor liver disease)

Diagnostic studies that may identifysource of acute bleeding include endoscopy, radionuclide scanning,and selective angiography.

If upper tract bleeding has stoppedor is intermittent, upper endoscopy can be performed to diagnoseesophagitis, gastritis, gastric or duodenal ulcer, Mallory-Weisstear, and esophageal varices.

If endoscopic exam is impossible to performbecause of continuous bleeding, radionuclide scan or selective angiographycan be performed. Technetium sulfur colloid scan can detect slow ongoingbleeding, whereas technetium red cell scan can detect slow intermittentbleeding. These techniques help localize site of bleeding, so thatother diagnostic studies can be performed.

Sulfur colloid scan can detect bleedingat rate as low as 0.1 mL/min, but only if bleeding is occurringat time of injection because half-life of tracer is <2.5mins. Labeled red cells remain in blood for 24 hrs, so technetiumred cell scan can detect intermittent bleeding.

If these scans fail to disclose siteof bleeding or bleeding is brisk, selective angiography should beperformed—angiography of celiac axis and superior mesentericartery for suspected upper tract bleeding, and superior mesentericand inferior mesenteric artery angiography for suspected lower tract bleeding.

Another advantage of angiography isthat therapeutic measures (e.g., vasopressin infusion and embolization)can be used if necessary.

If the bleeding is massive or uncontrolled,immediate surgery should be considered.

In stable child with lower tract bleeding,anus should be examined for anal fissure and rectum for polyp.

With bloodydiarrhea, bacterial stool culture should be performed, and examof stool for ova and parasites should be considered.

Technetium 99m–pertechnetatescan to identify ectopic gastric mucosa in Meckel diverticulum orintestinal duplication also should be considered. If diagnosis remainsuncertain, proctosigmoidoscopy should be performed. This may befollowed by colonoscopy or contrast studies.

Colonoscopy with biopsy may diagnosepolyps, colitis, IBD, hemangiomas, and malignant lesions. Air-contrastenema may diagnose intussusception.

With persistent undefined bleeding,upper tract endoscopy may be useful to identify ulcer, esophagealor gastric varices, or vascular lesion.

Upper GI radiographic series with smallbowel follow-through may diagnose lesions of esophagus, stomach,and duodenum as well as lesions of small bowel, including Crohndisease

Selective angiography may not revealsite of bleeding if bleeding is too slow, but it may suggest angiodysplasticlesion or tumor by revealing abnormal vascular pattern.

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Purpura and Bleeding: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Loss of Vascular Integrity

In many bleeding disorders, defective hemostasisoccurs at the site of small vessel injury without any abnormalityof coagulation.

Trauma

May producebleeding into skin. After birth trauma, purpura may occur on presenting part—heador extremity.

Young children commonly have bruiseson lower legs from falls.

Nonaccidental trauma (child abuse)should be suspected if bruises or associated fractures are unexplainedby history. Bruises found on buttocks, back, chest, abdomen, orface or in various stages of resolution or conforming to a beltor cord mark are suspicious of child abuse.

Infection

Most commoncauses of fever and petechiae are viral infections and group A streptococcalpharyngitis. Important to exclude meningococcemia and Rocky Mountainspotted fever because these are life-threatening diseases.

S. pneumoniae and H. influenzae typeb infections can present with septic shock and may be clinicallyindistinguishable from meningococcemia. Purpuric lesions also maybe seen with P. aeruginosa and S. aureus as well as N. gonorrhoeaeinfection.

Purpura fulminans, a severe form ofbleeding caused in part by loss of vascular integrity, is characterizedby large ecchymoses and gangrene of extremities. It is often foundin association with disseminated intravascular coagulation (DIC)and may accompany meningococcemia as well as septicemia from otherpathogens.

Henoch-Schönlein Purpura

Vasculitischaracterized by symmetric purpuric rash on buttocks and lower legs.Abdominal pain, arthritis of large joints, and blood in stools arefrequent findings. Hematuria with or without proteinuria also mayoccur.

Platelet count is normal.

Diagnosis is usually clinical.

Drugs

Several drugs (e.g., penicillins and sulfonamides)may cause increased capillary fragility and purpura. Corticosteroidsmay cause purpuric striae.

Langerhans Histiocytosis

Scaly rashwith papules and vesicles that also may be purpuric may occur. Othermanifestations include lymphadenopathy, hepatosplenomegaly, anemia,and thrombocytopenia.

Skin biopsy is diagnostic.

Ehlers-Danlos Syndrome

Caused bymutations in genes that code for collagen, collagen-modifying enzymes, andpossibly other extracellular matrix components.

Beighton et al. (1998) revised classificationin which 6 major types are now described. Most common types areknown as classical, hypermobility, and vascular types. Genetic transmissionis autosomal-dominant.

Classical type is characterized by skin hyperextensibility,joint hypermobility, atrophic scars that widen with age, and easybruising.

Hallmarks of hypermobility type aregeneralized joint hypermobility, hyperextensibility of skin, andchronic joint and limb pain.

Vascular type is characterized by extensivebruising, thin translucent skin, small joint hypermobility, andarterial/intestinal/uterine rupture.

Vitamin C Deficiency

Scurvy israre in U.S.

Occurrence is due to lack of ascorbicacid (vitamin C) in diet.

Characteristic findings include purpura,especially on lower extremities, gingival and soft tissue bleeding,and leg pain and swelling.

Clinical and radiographic findingsalong with low serum vitamin C level are diagnostic.

Hereditary Hemorrhagic Telangiectasia (Osler-Rendu-WeberDisease)

Autosomal-dominantdisorder characterized by multiple telangiectasias of skin and bleedingfrom respiratory and GI tracts. Gene locus of most frequent formhas been mapped to chromosome 9q34.1.

Epistaxis, GI bleeding, and skin bruisingare common findings.

Diagnosis is usually clinical.

Thrombocytopenia

May be due to increased platelet destruction,decreased platelet production, or platelet sequestration. More than1 mechanism may be responsible for thrombocytopenia, especiallywhen considering effects of infection and drugs.

Increased Platelet Destruction

In disorders that cause increased plateletdestruction, large platelets may be seen on blood smear. Exam ofbone marrow usually reveals normal or increased number of megakaryocytes.

Immune-Mediated

Neonatal Alloimmune Thrombocytopenia

About 98% ofpopulation have PL-A1 antigen on platelet surface. When maternal plateletslack this antigen, fetal platelets crossing placenta stimulate productionof maternal antibody, which results in their destruction.

Diffuse purpura usually occur at orsoon after birth.

Maternal platelet count is normal.Platelet typing of parents confirms diagnosis.

Maternal Autoimmune Thrombocytopenia

Maternalantibody crosses placenta, binds to infant's platelets,and destroys them. Maternal platelet count is usually low, whereasinfant platelet counts vary from near normal to <10,000/mm³.

Other than presence of generalizedpetechiae, these infants appear well.

Self-limited and usually resolves by3 mos of age.

Idiopathic Thrombocytopenic Purpura

Often followsonset of viral infections, with peak incidence at 2–6 yrsof age.

Hallmark is presence of purpura, whichcan vary from pinpoint petechiae to large ecchymoses in random distribution.

Antibodies against common plateletglycoproteins bind to platelet membrane, causing platelets to beremoved by tissue macrophages in the spleen. CBC is normal exceptfor marked thrombocytopenia. Platelet count is usually <50,000/mm³ andoften <10,000/mm³.

Bone marrow exam is unnecessary unlessleukemia is suspected.

Presence of epistaxis, gross hematuria,or bloody stools indicates more significant bleeding problem. Intracranialbleeding is most serious complication and is associated with plateletcount of <10,000/mm³.

Association of autoimmune hemolyticanemia or neutropenia with idiopathic thrombocytopenic purpura iscalled Evans syndrome.

Collagen Vascular Disease

Collagen vascular diseases (e.g., systemiclupus erythematosus) may produce immune-mediated thrombocytopenia.In some women with systemic lupus erythematosus, antiplatelet antibodiescross placenta, producing transient neonatal thrombocytopenia.

Drug-Induced Thrombocytopenia

Immune-mediated thrombocytopenia may be dueto drugs (e.g., sulfonamides, phenytoin, valproic acid, acetazolamide,carbamazepine, and quinidine). Purpura usually appear within 24hrs of exposure and begin to disappear after discontinuation ofthe drug.

Infection

Infection with several pathogens (see previoussection) may trigger onset of thrombocytopenia with or without DIC.

Hemolytic-Uremic Syndrome

Often aconsequence of diarrheal illness caused by E. coli 0157:H7.

Usual clinical findings include hemolyticanemia, thrombocytopenia, and renal failure.

Blood smear shows fragmented red cells(schistocytes).

Thrombotic Thrombocytopenic Purpura

Similarin many respects to hemolytic-uremic syndrome. However, usuallyoccurs in adults and tends to be chronic and relapsing.

Characterized by thrombocytopenic purpura,microangiopathic hemolytic anemia, and widespread thrombotic occlusionsin microcirculation, primarily in brain and liver.

Wiskott-Aldrich syndrome

Thrombocytopenic purpura, eczema, and impairedcell-mediated immunity with increased susceptibility to infectioncharacterize this X-linked recessive disorder. Platelet count usuallyis <50,000/mm³. See Chap. 53, Recurrent Infection.

Decreased Platelet Production

In disordersthat cause decreased platelet production, platelets in peripheralblood tend to be normal in size or small. Bone marrow exam showsabsence or decreased number of platelets.

In addition to conditions discussedin this section, infection also causes decreased platelet production.

Specific Platelet Disorders

Congenital Amegakaryocytic Thrombocytopenia

Rare disorder characterized by nonimmunethrombocytopenia with decreased marrow megakaryocyte counts. Redcells are macrocytic and fetal hemoglobin levels are increased.Pancytopenia and even leukemia may occur in some cases.

Thrombocytopenia–Absent Radius Syndrome

Neonatal thrombocytopenia and bilateral absenceof radii with presence of both thumbs characterize this autosomal-recessivedisorder.

Bone Marrow Suppression (Generalized)

Drugs, radiation,and infection including septicemia may cause bone marrow suppressionand thrombocytopenia.

Many cancer chemotherapeutic agentscause thrombocytopenia, including cytosine arabinoside, cyclophosphamide,methotrexate, and doxorubicin.

Chloramphenicol may cause dose-dependentreversible bone marrow suppression or dose-independent irreversiblemarrow aplasia.

Aplastic anemia and Fanconi anemiaare discussed in Chap. 45, Pallor(Anemia).

Bone Marrow Replacement

Normal bone marrow may be replaced by leukemiaof all types, metastatic neuroblastoma, and histiocytoses. The resultis platelet destruction and thrombocytopenia. See Chap. 38, Lymphadenopathy.

Megaloblastic Anemia

Folic acid and vitamin B₁₂ deficienciesmay be associated with thrombocytopenia and neutropenia due to inadequateproduction or increased destruction in bone marrow. See Chap. 45, Pallor (Anemia).

Platelet Sequestration

Hypersplenism

Can leadto platelet sequestration and thrombocytopenia.

Common causes include portal hypertensionand storage diseases.

Spleen is enlarged and firm. Plateletcount in such disorders usually is 50,000–100,000/mm³;therefore, significant bleeding is unusual.

Large Hemangiomas

Hemangioma-thrombocytopenia (Kasabach-Merritt)syndrome is autosomal-dominant disorder characterized by large hemangiomas,thrombocytopenia, microangiopathic hemolytic anemia, and consumptionof coagulation factors.

Abnormal Platelet Function

Qualitative platelet disorders should besuspected when platelet count is normal and bleeding time is prolonged.

Thrombasthenia (Glanzmann Disease)

Absenceor deficiency of glycoprotein IIb-IIIa complex is responsible forthis disorder of platelet aggregation. Genetic transmission is usuallyautosomal-recessive, but autosomal-dominant form has been described.Gene locus has been mapped to chromosome 17q21.32.

Usually presents in infancy or childhoodwith multiple bruises and purpura. Recurrent epistaxis and menorrhagiaare also common findings. Platelet count is normal, bleeding timeis prolonged, and platelet aggregation is absent on blood smear.

Assay of glycoprotein IIb-IIIa complexin platelet membrane establishes diagnosis.

Giant Platelet Syndrome (Bernard-Soulier Syndrome)

In thisautosomal-recessive disorder, glycoprotein Ib is absent from plateletmembrane. Also, glycoproteins IX and V have been shown to be deficientin this syndrome.

Characteristic features are easy bruisingand severe bleeding, especially at time of injury or surgery. Mildthrombocytopenia, giant platelets, prolonged bleeding time, anddefective in vitro platelet agglutination with ristocetin are usualfindings.

Demonstration of absence of glycoproteinIb in platelet membrane confirms diagnosis.

Storage Pool Deficiency

Deficiencyin number and contents of dense granules, alpha granules, or both,impairs platelet aggregation.

These rare disorders usually presentin childhood or adolescence with easy bruising and prolonged bleedingfrom minor cuts, epistaxis, or menorrhagia.

Electron microscopy of platelets isdiagnostic.

Drugs

Acetylsalicylic acid (aspirin) causes defectin second phase of platelet aggregation, and bleeding time is prolonged.NSAIDs, valproic acid, and high-dose penicillins also may causeplatelet dysfunction.

Uremia

Purpura as well as mucous membrane and GIbleeding can occur with uremia. Exact cause of platelet defect inuremia is unknown, but in vitro platelet aggregation is abnormaland platelet adhesion is decreased.

Coagulation Disorders

Factor Deficiencies

von Willebrand Disease

Caused byquantitative or qualitative decrease in von Willebrand factor (vWF),which is carrier protein for coagulation factor VIII. Gene for vWFhas been mapped to chromosome 12p13.3.

Superficial bruising, epistaxis, prolongedoozing from minor wounds, and prolonged heavy menstrual periodsmay occur.

Screening tests usually reveal prolongedactivated partial thromboplastin time (aPTT) and bleeding time.

Diagnosis can be confirmed by measuringvWF antigen and vWF ristocetin cofactor. The latter test is measureof vWF functional activity.

Factor VIII Deficiency (Hemophilia A)

Caused bymutations in Factor VIII gene, which has been mapped to Xq28.

Characteristic manifestations includebleeding into joints and muscle as well as prolonged bleeding fromwounds. Excessive bleeding may occur after circumcision; however,evidence of bleeding may not occur until a child begins to walk,when excessive bruising may be noted after frequent falls.

Risk of intracranial bleeding aftereven mild head trauma is always serious concern.

Prolonged aPTT is only abnormal coagulationscreening test, whereas decreased Factor VIII assay confirms diagnosis.

Factor IX Deficiency (Hemophilia B, Christmas Disease)

Factor IXgene has been mapped to Xq27.

Clinical presentation is indistinguishablefrom that of Factor VIII deficiency.

Screening coagulation tests revealprolonged aPTT. Decreased Factor IX assay confirms diagnosis.

Deficiencies of Factors I, II, V, VII, X, XI, and XIII

Clinicalpicture in Factor I deficiency is similar to that of platelet disorders,with bruising, epistaxis, and mucous membrane bleeding. Intracranialor joint bleeding is rare. Prothrombin time (PT), aPTT, and bleedingtime are prolonged. Prolongation of either thrombin time or reptilasetime or both should suggest this disorder. Very low or absent serumfibrinogen confirms diagnosis.

Factor II, V, VII, and X deficienciesmay present with easy bruising or prolonged bleeding after trauma,surgery, or dental work. Prolonged PT occurs and diagnosis is confirmedby factor assay. aPTT is normal with Factor VII deficiency, whereasboth PT and aPTT are prolonged with Factor II, V, and X deficiencies.

In Factor XI deficiency, mild bleedingincluding epistaxis or menorrhagia may occur. aPTT is prolongedand specific factor assay is diagnostic.

Easy bruising, prolonged umbilicalcord bleeding, and sometimes GI bleeding occur with Factor XIIIdeficiency. Screening coagulation tests are normal. Specific factorassay is diagnostic.

Vitamin K Deficiency

Resultsin failure of vitamin K–dependent coagulation factors (II,VII, IX, and X) to develop calcium-binding sites, which are necessaryfor effective coagulation function.

Because newborns have low vitamin Kstores, failure to give vitamin K immediately after birth may causegeneralized bleeding between 2 and 4 days of age. Hematochezia,melena, hematemesis, or bleeding from other sites also may occur.

History of failure to give vitaminK at birth; normal platelet count; normal or prolonged bleedingtime; prolonged PT and aPTT; decreased Factors II, VII, IX, andX; and reversal of prolonged PT and aPTT with decreased subsequentbleeding after vitamin K administration confirm diagnosis.

In infancy, childhood, and adolescence,causes of vitamin K deficiency include liver disease with cholestasisand fat malabsorption, prolonged antibiotic usage, and cystic fibrosis.Some clinical findings are easy bruising and ecchymoses as wellas mucous membrane and visceral hemorrhage. PT and aPTT are prolonged,whereas coagulation factors II, VII, IX, and X are decreased.

Disseminated Intravascular Coagulation

More commoncauses are septicemia, shock, and massive trauma.

Bleeding is secondary to consumptionof coagulation factors and platelets. Bruising, oozing from venipuncturesites, mucous membrane bleeding, and purpura may occur.

Certain lab findings confirm diagnosis:decreased platelet count; prolonged PT, aPTT, and bleeding time;decreased serum fibrinogen; increased fibrin split products; anddecreased Factors V and VIII.

Liver Disease

Coagulationabnormalities in acute liver failure include decreased synthesisof coagulation factors (the liver is site of synthesis of all coagulationfactors except Factor VIII); vitamin K malabsorption and decreasedactivity of Factors II, VII, IX, and X secondary to cholestasis;thrombocytopenia secondary to hypersplenism; production of abnormalfibrinogens; and DIC.

Bleeding as well as purpura may occur.

Lab findings usually show thrombocytopenia;prolonged PT, aPTT, and bleeding time; low serum levels of prothrombinand fibrinogen; and decreased serum levels of Factors V, VII, IX,and X.

Circulating Anticoagulants

May be associated with viral infections,malignancy, and collagen vascular disease. Usually prolonged aPTTfails to correct after adding normal plasma in test tube. In affectedindividuals, bleeding is uncommon, especially those with lupus anticoagulants.

Diagnostic Approach

Age, clinical findings, family history, andscreening tests (CBC with differential, platelet count, analysisof blood smear, PT and aPTT, and standardized Ivy bleeding time)are either diagnostic or narrow diagnostic possibilities in individualspresenting with purpura and bleeding.

Age

Neonates,especially preterm infants, have some features that may predisposeto purpura and bleeding. They have increase in capillary fragilityand decrease in platelet aggregation. Concentrations of vitaminK–dependent clotting factors are lower than adult normalvalues.

Diagnostic approach to purpura andbleeding depends on whether neonate is well or ill and whether plateletcount is normal or decreased.

In well neonate with normal platelet count,most common disorders that cause bleeding are trauma, vitamin Kdeficiency, Factor VIII or IX deficiency, and in utero exposureto drugs taken by mother (e.g., acetylsalicylic acid, phenytoin,or coumadin).

In well neonate with decreased plateletcount, most common disorders are alloimmune thrombocytopenia andmaternal autoimmune thrombocytopenia.

In ill neonate, common causes of bleedingand purpura are severe birth trauma, septicemia, and DIC. Othercauses include congenital infection (herpes simplex, cytomegalovirus,rubella, toxoplasmosis, syphilis), congenital leukemia, and osteopetrosis.

In infancy, childhood, and adolescence,most common causes of purpura and bleeding are accidental trauma,child abuse, Henoch-Schönlein purpura, idiopathic thrombocytopenicpurpura, leukemia, infection, and Factor VIII and IX deficiencies.

Clinical Findings

Typically,individuals with loss of vascular integrity have superficial bleedingwith purpura. Diagnosis of loss of vascular integrity depends onclinical recognition of vascular disorder and absence of plateletor coagulation disorder.

Individuals with thrombocytopenia orplatelet dysfunction usually have purpura and superficial bleedingof mucous membranes including epistaxis and GI tract bleeding. Alsomay have hematuria, menorrhagia, and intracranial bleeding. Normalplatelet count with prolonged bleeding time suggests qualitativeplatelet defect.

Individuals with Factor VIII or IXdeficiency, which are most common coagulation disorders, have recurrentbruising and bleeding into joints and muscle.

Family History

Positivefamily history may help confirm diagnosis.

As general rule, genetically transmitteddisorders usually have their onset in infancy with appearance ofrecurrent purpura and bleeding.

Acquired disorders are usually acute,variable in time of onset, and typically associated with infection,drug reactions, malignancy, or immunologic disorders.

Screening and Diagnostic Tests

A plateletcount of <150,000/mm³ isabnormal. Bleeding is rare with platelet count of >30,000/mm³.Large platelets are usually seen on blood smear in disorders inwhich thrombocytopenia is due to increased platelet destruction.Normal-sized platelets are usually seen in disorders in which thrombocytopeniais due to decreased production. When thrombocytopenia is associatedwith neutropenia or pancytopenia, bone marrow aspirate should beperformed searching for evidence of aplastic anemia, leukemia, orother malignancies.

With normal platelet count but abnormalbleeding time, most likely diagnoses are von Willebrand disease,aspirin ingestion, qualitative defect in platelet function, anduremia. Tests for renal function, vWF antigen, vWF ristocetin cofactor,and platelet function should be considered.

Possible causes of prolonged PT includeFactor VII deficiency, mild vitamin K deficiency, and liver disease.

Prolonged aPTT may be caused by FactorVIII, IX, XI, and XII deficiencies; von Willebrand disease; andpresence of circulating anticoagulant. There is no clinical bleedingwith Factor XII deficiency.

Possible causes of prolonged PT andaPTT include liver disease, DIC, vitamin K deficiency, congenitalfactor deficiencies (II, V, and X), and fibrinogen disorders (afibrinogenemia,hypofibrinogenemia). Liver function tests should be performed withsuspected liver disease. Otherwise, thrombin time, serum fibrinogen,fibrin split products, and assays for Factors II, V, and X shouldbe performed as indicated. Serum fibrinogen is decreased in congenitalafibrinogenemia, DIC, and sometimes in severe liver disease.

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Vaginal Bleeding: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Before Normal Menarche

In addition to conditions discussed in thissection, genital tract tumors can cause vaginal bleeding (see section Genital Tract Tumors below).

Trauma

Blunt traumafrom a fall or bicycle injury is common cause of vaginal bleedingduring childhood. Abrasions and lacerations of vulva, vagina, and,less commonly, cervix may occur.

Sexual abuse or rape is another commoncause of genital tract injury and bleeding.

Trauma also may injure urethra, bladder,rectum, and abdominal viscera. Exam of these areas should be performedin anyone with significant vaginal or vulvoperineal injury. Dependingon circumstances and age of child, vaginal exam under general anesthesiamay be necessary.

Vulvovaginitis

Nonspecificvulvovaginitis usually presents with nonbloody discharge. Pathogens thatmay be associated with blood-tinged discharge are Shigella speciesand group A Streptococcus. Vaginal culture is diagnostic.

Some children with pinworm infestationmay scratch so much that excoriation and bleeding occur. Seeingthreadlike white pinworms or viewing pinworm eggs under microscopeis diagnostic.

Foreign Body

Highestincidence of vaginal foreign body is at 2–4 yrs of age.

Some common items are pins, paper clips,beads, crayons, and toilet paper.

Vaginal bleeding may occur with orwithout discharge, which is usually foul smelling.

Sometimes foreign body can be palpableon rectal exam. Pelvic radiography may be diagnostic if foreignbody is radiopaque.

Vaginoscopy is usually necessary fordiagnosis and removal, and sometimes it is necessary to performthis exam under anesthesia.

Urethral Prolapse

Is the protrusion of mucosa through the urethralmeatus. Small urethral opening is seen in middle of inflamed, edematous,purplish tissue that is above and separate from vaginal introitus.Mild bleeding appears to come from the vagina, but its origin isthe prolapse.

Condyloma Acuminata

Human papillomavirus (HPV) is the cause of condyloma acuminata, which are skin-coloredwarts with cauliflower-like appearance that can involve labia, perinealarea, and vagina.

Because incubation period may be manymonths, child with warts before age 2 yrs may have been infectedas infant. Whether longer intervals result in this infection isunknown.

Nonsexual contact also may be possibleexplanation in infants and children. However, possibility of sexualabuse should be considered regardless of age, because this is asexually transmitted infection.

Diagnosis of condyloma acuminata isusually clinical. Biopsy is definitive, and specific HPV type canbe established by molecular techniques.

Exogenous Hormone Preparations

Exogenous hormone preparations that containestrogens may induce breast development and uterine bleeding. Historyand physical exam are usually diagnostic.

Precocious Puberty

Precocious puberty with premature onset ofmenses can produce vaginal bleeding (see Chap. 48, Precocious Puberty).

Premature Menarche

Isolatedmenses that occur earlier than normal menstruation and without otherevidence of sexual development characterize the rare condition ofpremature menarche.

Intermittent spotting or bleeding maycontinue for several days at a time. These episodes may occur onceor in cycles for several months. Puberty occurs at normal time,and menstrual cycles are normal.

This disorder is most likely due totransient production of estrogen by ovary.

In some girls, abdominal U/Sreveals ovarian follicular cysts.

Hypothyroidism

With primary severe hypothyroidism, cross-reactivityof high levels of TSH with ovarian follicle-stimulating hormonereceptors can cause increase in estrogen secretion and subsequentbreast development and vaginal bleeding. Regression occurs followingtreatment with thyroid hormone.

After Menarche

Trauma

Injuriesto vulva and vagina from falls or straddle injuries may cause vaginalbleeding. Sexual assault is another cause of vaginal trauma andbleeding.

Erosions of cervix may occur in girlswho have had sexual intercourse or who have borne a child. Intermittentvaginal spotting is frequent occurrence.

Diagnosis is confirmed by exam of thecervix.

Vulvovaginitis, Foreign Body, and Pelvic Inflammatory Disease

See previous section. In adolescent girls,most common foreign body is retained tampon. Pelvic inflammatorydisease is discussed in Chap.71, Vaginal Discharge.

Cervicitis

Infection with C. trachomatis, N. gonorrhoeae,herpes simplex virus, or T. vaginalis may cause cervicitis. Cervixis inflamed and mucopurulent discharge may be visible. Diagnosisof these infections is discussed in Chap.71, Vaginal Discharge.

Cervical Polyps

May cause intermenstrual spotting in adolescentgirls, especially in those who have borne children or who have hadgonorrhea. Exam of cervix is diagnostic.

Anovulatory Cycles

In adolescence,uterus is most often source of abnormal vaginal bleeding. Most commoncause is anovulatory cycles, which lead to dysfunctional uterinebleeding.

During first years after menarche,bleeding may be frequent, prolonged, irregular, and excessive.

Prolonged anovulation increases riskfor dysfunctional uterine bleeding. Reason seems to be an impairednegative feedback system. Unopposed estrogen produces thickenedendometrium, and without adequate progesterone, sloughing occurswith potential for heavy bleeding.

This is diagnosis of exclusion.

Ovulation

Mild, self-limited, midcycle bleeding for1–2 days may be associated with transient decrease in serumestrogen that occurs at time of ovulation. Bleeding also may beaccompanied by mild pain (mittelschmerz).

Endometriosis

Irregular menses with anovulation has beenassociated with endometriosis, which is discussed in Chap. 2, Abdominal Pain.

Genital Tract Tumors

Benign andmalignant tumors of female genital tract are rare in pediatric population butcan present with abnormal vaginal bleeding.

Cervical papilloma may present withvaginal bleeding, and soft, friable polypoid mass may be seen arisingfrom cervix.

Adenocarcinoma of vagina or cervixand rhabdomyosarcoma (sarcoma botryoides) may present with vaginalbleeding or blood-tinged vaginal discharge. History of maternalingestion of diethylstilbestrol or other synthetic estrogen duringpregnancy may exist with adenocarcinoma. Mass may be seen on pelvicexam with vaginal or cervical tumor.

Uterine tumors may present with vaginalbleeding, mass protruding from os, enlarged uterus, or pelvic mass.

Although genital tract tumors are rare,they should be considered in any child or adolescent who has abnormalgenital tract bleeding, vaginal discharge, tissue protruding fromvagina, abdominal enlargement, or pelvic mass.

Vaginoscopy, pelvic U/S, andlaparoscopy are useful in diagnosis. Histologic diagnosis is definitive.

Bleeding Disorders

Presenceof excessive or gushing bleeding with cyclic menses from time ofmenarche should suggest coagulation disorder [e.g., thrombocytopenia(idiopathic thrombocytopenic purpura, leukemia, aplastic anemia),von Willebrand disease, or, rarely, a factor deficiency].

CBC, blood smear, platelet count, prothrombintime, activated partial thromboplastin time, and bleeding time effectivelyscreen for most bleeding disorders. See Chap. 52, Purpura and Bleeding,for discussion of these disorders.

Endocrine Disorders

Irregularmenses may be associated with hypothyroidism, hyperthyroidism, hyperprolactinemia,and adrenal disorders (Addison disease, Cushing syndrome, late-onsetcongenital adrenal hyperplasia).

Ovarian disease (e.g., steroid-secretingovarian tumors, polycystic ovary syndrome, and premature ovarianfailure) also may cause abnormal bleeding. Polycystic ovary syndromeshould be considered in adolescent with hirsutism, acanthosis nigricans,acne, and obesity.

Systemic Diseases

Menstrualfunction is usually normal with diabetes mellitus, but irregularcycles can occur, especially with poorly controlled disease.

Females with chronic renal diseaseon dialysis have irregular menses that vary from occasional spottingto dysfunctional uterine bleeding.

Drugs

Use of oralcontraceptives may produce intermittent vaginal spotting or bleeding,especially during initial 3 mos of use. Intermittent spotting orbreakthrough bleeding also may occur with injectable medroxyprogesteroneand long-acting progesterone implants.

Medications (e.g., anticoagulants andplatelet inhibitors) may be associated with excessive bleeding.

Irregular menses may be caused by tricyclicantidepressants and valproic acid. Anabolic steroids also may produceanovulatory cycles with irregular bleeding.

Complications of Pregnancy

Before 20 Wks' Gestation

Pregnant female with uterine bleeding before20 wks' gestation has complicated intrauterine pregnancy,ectopic pregnancy, or molar pregnancy.

Intrauterine Pregnancy

Threatenedabortion is diagnosed if U/S shows intrauterine pregnancywith viable fetus.

Spontaneous abortion is consideredinevitable when there is gross rupture of membranes in presenceof cervical dilatation.

In incomplete abortion, tissue fragmentshave already been expelled from uterus. Bleeding is usually heavy,and painful uterine contractions may occur.

Missed abortion is retention of deadproducts of conception in utero for several weeks. After fetal death,vaginal bleeding may or may not occur. Occasionally, serious coagulationdefects may occur with prolonged retention of dead fetus.

Ectopic Pregnancy

Classically,ectopic pregnancy presents with pelvic pain, vaginal bleeding, andamenorrhea.

Although most females have pelvic pain,the other 2 symptoms are less consistent.

Results of urine or serum pregnancytest are positive. If question exists about possibility of ectopicpregnancy in nonemergent situation, serial quantitative serum humanchorionic gonadotropin pregnancy tests are useful.

Pelvic U/S can help in demonstratingpresence of normal intrauterine pregnancy or mass.

Laparoscopy should be considered ifdiagnosis remains uncertain.

If vaginal bleeding occurs during firstor second trimester with signs of cardiovascular compromise, rupturedectopic pregnancy is possible. Immediate fluid resuscitation ismandatory, and emergency laparoscopy or laparotomy may be necessary.If patient is stable, pelvic U/S may help clarify diagnosis.

Molar Pregnancy

Hydatidiform mole presents with uterine bleedingusually during first trimester. Bleeding may be intermittent orcontinuous. Uterus is often larger than expected for duration ofgestation. Pelvic U/S is diagnostic.

After 20 Wks' Gestation

Third-trimester bleeding may indicate anemergency due to placenta previa or abruptio placenta, and obstetricevaluation should be undertaken without delay.

Diagnostic Approach

Before Menarche

Trauma,vulvovaginitis, and foreign body are most common causes of abnormalvaginal bleeding before menarche.

Complete history and physical examshould be performed, including exam of external genitalia and vaginalintroitus. Exam under anesthesia is necessary with significant trauma,foreign body that cannot be removed, or suspected genital tumor.

Approach to precocious puberty andvulvovaginitis is described in Chap.48, Precocious Puberty, and Chap. 71,Vaginal Discharge,respectively.

After Menarche

Girls withabnormal vaginal bleeding should have complete history and physicalexam, which includes speculum exam of vagina and cervix and bimanualvaginal exam. Source of bleeding must be determined, whether vulvar,vaginal, cervical, or uterine. If significant vaginal trauma hasoccurred from injury, exam of vagina and cervix may have to be performedunder anesthesia.

Diagnostic approach to vulvovaginitisin this age group is discussed in Chap.71, Vaginal Discharge. If uncertainty about pregnancyexists, urine pregnancy test should be performed.

If bleeding is from normal-sized uterus,most common cause is from anovulatory cycle, but this is diagnosisof exclusion. Other common causes include ovulation and oral contraceptiveuse. Abnormal vaginal discharge and abdominal pain suggest pelvicinflammatory disease. Heavy cyclic bleeding suggests coagulationdisorder, and certain tests should be performed: CBC with differential,analysis of blood smear, platelet count, prothrombin time, activatedpartial thromboplastin time, and bleeding time. Uterine tumors arerare in adolescent age group.

If bleeding is from enlarged uterus,it is likely that there is complication of pregnancy (e.g., spontaneousabortion, ectopic pregnancy, placenta previa, or abruptio placenta).If individual is <20 wks pregnant and has normal BP, eitherectopic pregnancy or spontaneous abortion is likely. In either case, pregnancytest should be performed unless it is a known pregnancy, and obstetricconsultation should be obtained.

In girl who is <20 wks pregnantand hypotensive with severe bleeding, ectopic pregnancy is mostlikely cause. If uterine bleeding occurs during third trimesterof pregnancy, placenta previa or abruptio placenta is likely. Externalgenitalia should be inspected and obstetric consultation shouldbe requested. An intravenous line should be placed, CBC drawn, andblood sent for type and cross-match. If patient is hypotensive,fluid resuscitation should be started immediately.

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Gum bleeding [Gingival bleeding]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If gum bleeding isn't an emergency, obtain a history. Find out when the bleeding began. Has it been continuous or intermittent? Does it occur spontaneously or when the patient brushes his teeth or flosses? Have the patient show you the site of the bleeding, if possible.

Find out if the patient or any family members have bleeding tendencies; for example, ask about easy bruising and frequent nosebleeds. How much does the patient bleed after a tooth extraction? Does he have a history of liver or spleen disease? Next, check the patient's dental history. Find out how often he brushes his teeth, flosses, and goes to the dentist and what kind of toothbrush and floss he uses. Has he seen a dentist recently? To evaluate nutritional status, have the patient describe his normal diet and alcohol intake. Finally, note the prescription and over-the-counter drugs he takes.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Vaginal bleeding, postmenopausal: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Determine the patient's age and her age at menopause. Ask when she first noticed the abnormal bleeding then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her menses regular? If not, ask her to describe menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient's mother and ask about a family history of gynecologic cancer. Determine whether the patient has associated symptoms and if she's taking estrogen.

Observe the external genitalia, noting the character of vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient's breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Hematochezia [Rectal bleeding]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If hematochezia isn't immediately life-threatening, ask the patient to fully describe the amount, color, and consistency of his bloody stools. (If possible, also inspect and characterize the stools yourself.) How long have the stools been bloody? Do they always look the same, or does the amount of blood seem to vary? Ask about associated signs and symptoms.

Next, explore the patient's medical history, focusing on GI and coagulation disorders. Ask about the use of GI irritants, such as alcohol, aspirin, and other nonsteroidal anti-inflammatory drugs (NSAIDs).

Begin the physical examination by checking for orthostatic hypotension, an early sign of shock. Take the patient's blood pressure and pulse while he's lying down, sitting, and standing. If systolic pressure decreases by 10 mm Hg or more or if the pulse rate increases by 10 beats/minute or more when he changes position, suspect volume depletion and impending shock.

Examine the skin for petechiae or spider angiomas. Palpate the abdomen for tenderness, pain, or masses. Also note lymphadenopathy. Finally, a digital rectal examination must be done to rule out rectal masses or hemorrhoids.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Bleeding Under the Skin: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

RECTAL BLEEDING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

VAGINAL BLEEDING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The differential diagnosis of vaginal bleeding depends on the clinical picture. The most common cause of unexpected bleeding in all women is dysfunctional uterine bleeding due to imbalance of estrogen and progesterone during the menstrual cycle. Nevertheless, vaginal bleeding in a postmenopausal woman must be considered a malignancy until proven otherwise. Vaginal bleeding in the prepubertal female should prompt an investigation for child abuse or incest as well as neoplasm. A careful vaginal examination with the patient fully relaxed is most important. A rectovaginal examination must be performed to palpate masses in the cul-de-sac. Any vaginal discharge must be cultured for gonococci and Chlamydia organisms to rule out PID. A biopsy is done of any suspicious lesion of the vagina or cervix, and a Pap smear is performed. If the diagnosis is uncertain at this point, a gynecology consult is in order. A dilation and curettage (D & C) or endometrial biopsy must be done if uterine carcinoma is suspected. In women of childbearing age, a routine pregnancy test should be done, but if an ectopic pregnancy is suspected a serum beta-human chorionic gonadotropin (β -hCG) subunit pregnancy test will be more definitive. Ultrasonography will often determine if a pelvic mass is an ectopic pregnancy. Ultrasonography will also be helpful in diagnosing ovarian cysts and tumors, but a computed tomography (CT) scan of the pelvis can be more definitive.

HEMATURIA
I C A T E

Intoxication Congenital Allergic or Autoimmune Trauma Endocrine

Malformation Disorders

Intercourse Trauma to hymen

Foreign body

Placenta previa Laceration

Birth control pills Estrogens and other hormones
Anteversion of uterus Retroversion or flexion of uterus
Idiopathic thrombocytopenic purpura
Foreign body Abortion, induced
Menopause Dysfunctional bleeding Abruptio placenta

Hypopituitarism Hypothyroidism Stein–Leventhal ovaries

Toxic suppression of platelets Heparin Warfarin
Lupus erythematosus Surgery

Dysfunctional uterine bleeding is most often physiologic. However, a granulosa cell tumor of the ovary can be the cause. Ultrasonography or a CT scan may be able to reveal such a tumor, but culdoscopy or laparoscopy may be required. If the dysfunctional bleeding is thought to be due to hypothyroidism or hyperthyroidism, a thyroid profile may be done. If it is believed to be due to a pituitary adenoma, a magnetic resonance imaging (MRI) of the brain and serum LH and FSH assays should be done. Anemia and systemic disease must be ruled out also (see tests listed below). If pathologic causes of dysfunctional uterine bleeding are excluded, normal cyclic bleeding may be reestablished by a course of cyclic estrogen and progesterone or progesterone alone (a “medical D & C”). If this is unsuccessful, a surgical D & C is required.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

» Next page: Signs of Hemorrhage

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I	C	A	T	E
Intoxication	Congenital	Allergic or Autoimmune	Trauma	Endocrine
	Malformation			Disorders
			Intercourse Trauma to hymen
			Foreign body


	Placenta previa		Laceration

Birth control pills Estrogens and other hormones	Anteversion of uterus Retroversion or flexion of uterus	Idiopathic thrombocytopenic purpura	Foreign body Abortion, induced	Menopause Dysfunctional bleeding Abruptio placenta




				Hypopituitarism Hypothyroidism Stein–Leventhal ovaries
Toxic suppression of platelets Heparin Warfarin		Lupus erythematosus	Surgery

Dr. Huntley's Diagnosis Checklist

Diagnosis of Hemorrhage

Hemorrhage Diagnosis: Book Excerpts

Diagnosis of Hemorrhage: medical news summaries:

Diagnostic Tests for Hemorrhage: Online Medical Books

BLEEDING GUMS: Ask the following questions: (Algorithmic Diagnosis of Symptoms and Signs)

DIAGNOSTIC WORKUP

PURPURA AND ABNORMAL BLEEDING: Ask the Following Questions: (Algorithmic Diagnosis of Symptoms and Signs)

DIAGNOSTIC WORKUP

RECTAL BLEEDING: Ask the Following Questions: (Algorithmic Diagnosis of Symptoms and Signs)

DIAGNOSTIC WORKUP

Abnormal Uterine Bleeding: Differential Diagnosis (In a Page: Signs and Symptoms)

Workup and Diagnosis

Bleeding (Excessive): Differential Diagnosis (In a Page: Signs and Symptoms)

Workup and Diagnosis

GI Bleeding - Hematemesis: Differential Diagnosis (In a Page: Signs and Symptoms)

Workup and Diagnosis

GI Bleeding - Melena & Hematochezia: Differential Diagnosis (In a Page: Signs and Symptoms)

Workup and Diagnosis

Retinal Hemorrhage: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Workup and Diagnosis

Abnormal Vaginal Bleeding: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Workup and Diagnosis

BLEEDING UNDER THE SKIN: Approach to the Diagnosis (Differential Diagnosis in Primary Care)

RECTAL BLEEDING: Approach to the Diagnosis (Differential Diagnosis in Primary Care)

VAGINAL BLEEDING: Approach to the Diagnosis (Differential Diagnosis in Primary Care)

Gum bleeding [Gingival bleeding]: History and physical examination (Handbook of Signs & Symptoms (Third Edition))

Vaginal bleeding, postmenopausal: History and physical examination (Handbook of Signs & Symptoms (Third Edition))

Abnormal premenopausal bleeding: Diagnosis (Professional Guide to Diseases (Eighth Edition))

Dysfunctional uterine bleeding: Diagnosis (Professional Guide to Diseases (Eighth Edition))

Hereditary hemorrhagic telangiectasia: Diagnosis (Professional Guide to Diseases (Eighth Edition))

Postmenopausal bleeding: Diagnosis (Professional Guide to Diseases (Eighth Edition))

Gum bleeding [Gingival bleeding]: History and physical examination (Professional Guide to Signs & Symptoms (Fifth Edition))

Vaginal bleeding, postmenopausal: History and physical examination (Professional Guide to Signs & Symptoms (Fifth Edition))

Hematochezia [Rectal bleeding]: History and physical examination (Professional Guide to Signs & Symptoms (Fifth Edition))

Gastrointestinal Bleeding: History (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Physical examination

Postmenopausal Bleeding: History (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Physical examination

Rectal Bleeding: History (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Physical examination

Purpura/Petechiae/Excessive Bleeding: Differential Overview (Field Guide to Bedside Diagnosis)

Diagnostic Approach

Gastrointestinal Bleeding: Differential Overview (Field Guide to Bedside Diagnosis)

DIagnostic Approach

Vaginal Bleeding: Differential Overview (Field Guide to Bedside Diagnosis)

Diagnostic Approach

Vaginal bleeding, postmenopausal: History (Signs & Symptoms: A 2-in-1 Reference for Nurses)

Gum bleeding: History (Signs & Symptoms: A 2-in-1 Reference for Nurses)

Gastrointestinal Bleeding: Clinical Features and Diagnosis (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Upper Gastrointestinal Bleeding

Nose

Mouth and Pharynx

Esophagus

Esophagitis

Foreign Body

Varices

Duplication

Gastroesophageal Junction

Stomach

Gastritis

Ulcer

Duplication

Vascular Malformation

Neoplasm

Duodenum

Ulcer

Foreign Body

Duplication

Hemobilia

Other

Swallowed Blood

Coagulopathy

Hemorrhagic Disease of the Newborn (Vitamin K Deficiency)

Disseminated Intravascular Coagulation

Drugs

Lower Gastrointestinal Tract Bleeding

Intestine

Cow Milk/Soy Protein Sensitivity

Necrotizing Enterocolitis

Dr. Huntley's
Diagnosis
Checklist

BLEEDING GUMS: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

PURPURA AND ABNORMAL BLEEDING: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

RECTAL BLEEDING: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

Abnormal Uterine Bleeding: Differential Diagnosis
(In a Page: Signs and Symptoms)

Bleeding (Excessive): Differential Diagnosis
(In a Page: Signs and Symptoms)

GI Bleeding - Hematemesis: Differential Diagnosis
(In a Page: Signs and Symptoms)

GI Bleeding - Melena & Hematochezia: Differential Diagnosis
(In a Page: Signs and Symptoms)

Retinal Hemorrhage: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Abnormal Vaginal Bleeding: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

BLEEDING UNDER THE SKIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

RECTAL BLEEDING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

VAGINAL BLEEDING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Gum bleeding [Gingival bleeding]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Vaginal bleeding, postmenopausal: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Abnormal premenopausal bleeding: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Dysfunctional uterine bleeding: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Hereditary hemorrhagic telangiectasia: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Postmenopausal bleeding: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Gum bleeding [Gingival bleeding]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Vaginal bleeding, postmenopausal: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Hematochezia [Rectal bleeding]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Gastrointestinal Bleeding: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Postmenopausal Bleeding: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Rectal Bleeding: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Purpura/Petechiae/Excessive Bleeding: Differential Overview
(Field Guide to Bedside Diagnosis)

Gastrointestinal Bleeding: Differential Overview
(Field Guide to Bedside Diagnosis)

Vaginal Bleeding: Differential Overview
(Field Guide to Bedside Diagnosis)

Vaginal bleeding, postmenopausal: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Gum bleeding: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Gastrointestinal Bleeding: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Purpura and Bleeding: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)