Diagnostic Tests for Hemorrhage
Hemorrhage Tests: Book Excerpts
Hemorrhage Diagnosis: Book Excerpts
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BLEEDING GUMS:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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
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
Gum bleeding [Gingival bleeding]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth 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 intake of alcohol. Finally, note any 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 any teeth.
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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))
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: 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:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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.
Laboratory evaluation
A. Basic laboratory studies should include a complete blood count with particular attention to the hematocrit, coagulation studies [prothrombin time (PT) and partial thromboplastin time (PTT)], liver function tests (LFTs), serum chemistries (blood urea nitrogen is elevated disproportionately to creatinine in patients with GI blood loss), electrocardiogram (ECG), and NG aspirate analysis. Acutely, the hematocrit is a poor indicator of blood loss; however, serial hematocrits can be useful in assessing ongoing blood loss. A prolonged PT or PTT suggests an underlying coagulopathy. Elevated LFTs suggest underlying liver disease. An ECG is important, especially in elderly patients, to search for evidence of cardiac ischemia. Finally, the NG aspirate is essential. If the aspirate is bright red, or “coffee grounds” in appearance, an upper GI source is likely.
B. Endoscopy plays a central role in the diagnosis and management of GI bleeding. Fiberoptic endoscopy is 90% accurate in pinpointing the source of upper GI bleeding. In addition, the endoscope can also be used to deliver therapy directly.
C. Anoscopy can be used to identify the source of lower GI bleeding; however, the yield is poor (5). Often the site of bleeding cannot be directly visualized or the volume of bleeding is sufficiently heavy to obscure clear visualization.
D. Nuclear medicine studies are useful in grossly localizing bleeding sources to the small intestine, right colon, or left colon. Nuclear scanning is also useful in detecting Meckel’s diverticulae. These images can detect ongoing GI bleeding with a sensitivity of blood loss at 0.05 to 0.1 ml/minute.
E. Angiography can also identify the source of lower GI bleeding. It is not as sensitive as nuclear scanning, requiring a blood loss of more than 0.5 ml/minute.
Diagnostic assessment
The key to the successful approach to GI bleeding is ensuring the hemodynamic stability of the patient. Once done, a systematic search for the source of the bleeding should be undertaken. Although often unreliable, a careful patient history can provide valuable clues to factors that may predispose the patient to hemorrhage from a particular site within the GI tract. Physical examination (including placement of a NG tube) can further delineate whether an upper source or a lower source is most likely. The key diagnostic modality in GI bleeding is fiberoptic endoscopy. Following the clues provided by a careful history and physical examination, targeted endoscopy is then used to definitively identify the source of bleeding. In the rare cases where endoscopy is unable to adequately identify the source of GI bleeding, specialized nuclear medicine and angiographic studies can be used.
References
1. Zimmerman HM, Curfman K. Acute gastrointestinal bleeding. AACN Clin Issues 1997;8(3):449–458.
2. Laine L. Acute and chronic gastrointestinal bleeding. In: Feldman M, Sleisinger MH, Scharschmidt BF, eds: Gastrointestinal and liver disease: pathophysiology, diagnosis, and management. Philadelphia: WB Saunders, 1998:198–218.
3. McGuirk TD, Coyle WJ. Upper gastrointestinal tract bleeding. Emer Med Clin N Am 1996;14(3):523–545.
4. Zuccaro G. Management of the adult patient with acute lower gastrointestinal bleeding. Am J Gastroenterol 1998;93(8):1202–1208.
5. Bono MJ. Lower gastrointestinal bleeding. Emer Med Clin N Am 1996;14(3):547–556.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Postmenopausal Bleeding:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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).
Testing
A. Office laboratory testing. Urinalysis, stool guaiac testing, or both can be useful to look for nongenital sources of blood. A complete blood count may be helpful in assessing the degree of blood loss and likelihood of infection. Testing for gonorrhea and chlamydia may be warranted when tenderness or fever is present.
B. Pap smear. Many sources recommend a pap smear as part of the evaluation, although its diagnostic yield in these cases is low. Cervical lesions or friability raise the possibility of a cervical bleeding source. Endometrial cells found on the pap smear of a postmenopausal woman not on HRT warrants further evaluation of the endometrium.
C. Biopsy
1. Visible lesions of the vulva, vagina, or cervix should be sent for biopsy.
2. In the absence of a clear nonuterine source of bleeding, endometrial biopsy is usually recommended. This office test can cost-effectively identify endometrial hyperplasia and carcinoma, with a sensitivity of 85% to 95% (3), and it is lower in cost and risk than other procedures (2).
3. Traditional wisdom required dilation and curettage (D&C) for diagnosis if endometrial biopsy was negative. Recent evidence indicates this is unlikely to be of benefit (despite higher risk and cost), except in cases where other procedures are not possible (2–5).
4. If bleeding continues after normal biopsy, consider repeat biopsy or assessment by another method (5).
D. Diagnostic imaging
1. Palpable adnexal abnormalities should be evaluated by ultrasound or other imaging as appropriate.
2. Transvaginal ultrasound (TVUS) is gaining popularity as an alternative or adjunct to endometrial biopsy. A clearly identifiable endometrial stripe less than 4 or 5 mm in thickness is highly unlikely to contain hyperplasia or carcinoma, and biopsy may not be necessary (2,4). Fluid in the endometrial cavity has been associated with carcinoma, and its presence warrants further investigation (5). TVUS should not be used in place of biopsy in women on tamoxifen, as the drug is known to cause misleading ultrasound findings (3,5).
3. Hysteroscopy is becoming the “gold standard” against which other methods of endometrial assessment are compared (4,5). Flexible hysteroscopy allows direct visualization of the endometrium in the office setting, and can be used for directed biopsy and removal of small polyps. Rigid hysteroscopy allows greater intervention, but requires greater anesthesia.
4. Sonohysterography (ultrasound evaluation after instillation of fluid into the endometrial cavity) appears to offer promise as another alternative that provides additional information on the uterine architecture (3,5). This is the subject of ongoing study, especially in comparison with hysteroscopy, which provides similar information and may allow simultaneous biopsy of identified lesions.
Diagnostic assessment
Initial clinical evaluation may identify a nonuterine source. Postcoital spotting in conjunction with vaginal atrophy or cervical friability suggests cervical or vaginal mucosal bleeding. Gross hematuria or visibly bleeding hemorrhoids suggest that the bleeding source is not genital. If no other source is identified, however, the key to diagnosis is imaging and tissue sampling of the endometrium. A thin endometrial stripe in a woman in a low-risk category suggests endometrial atrophy. Findings on biopsy can include atrophy, proliferative changes, various degrees of hyperplasia (simple, complex, and atypical, in increasing order of risk), or carcinoma. If neither biopsy nor TVUS provides sufficient information, hysteroscopy is the recommended next step. D&C should be reserved for cases in which other methods are unsuccessful or unavailable.
References
1. Shelly MS. Endometrial biopsy. Am Fam Physician 1997;55(5):1731–1736.
2. Feldman S, Berkowitz RS, Tosteson ANA. Cost-effectiveness of strategies to evaluate post-menopausal bleeding. Obstet Gynecol 1993;81(6):968–975.
3. O’Connell LP, Fries MH, Zeringue E, Brehm W. Triage of abnormal postmenopausal bleeding: a comparison of endometrial biopsy and transvaginal sonohysterography versus fractional curettage with hysteroscopy. Am J Obstet Gynecol 1998;178(5):956–961.
4. Emanuel MH, Verdel MJ, Wamsteker K, Lammes FB. A prospective comparison of transvaginal ultrasonography and diagnostic hysteroscopy in evaluation of patients with abnormal uterine bleeding: clinical implications. Am J Obstet Gynecol 1995;172(2):547–552.
5. Good AE. Diagnostic options for assessment of postmenopausal bleeding. Mayo Clin Proc 1997;72:345–349.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Rectal Bleeding:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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).
Testing
A. Anoscopy. The anoscope allows inspection for fissures, fistulas, bleeding and nonbleeding hemorrhoids, and rectal friability.
B. Rigid proctosigmoidoscopy has given way to flexible sigmoidoscopy; it visualizes well the distal 25 cm of the proctosigmoid area for neoplasia, friability, polyps, ulcers, or hemorrhoids. Rigid sigmoidoscopy has a sensitivity of 69% and specificity of 95% in determining the presence or absence of disease (1).
C. Flexible sigmoidoscopy is much better tolerated by the patient than rigid proctosigmoidoscopy. It visualizes the distal 60 to 70 cm of the colon and detects similar findings as rigid proctosigmoidoscopy with similar sensitivity and specificity.
D. Air contrast barium enema demonstrates polyps, masses, mucosal irregularities, diverticulae and inflammatory bowel disease with a sensitivity of 52% and a specificity of 98% (1). When used in combination with sigmoidoscopy, it has a sensitivity of 96% and specificity of 76% with a positive predictive value of 55% (1).
E. Stool guaiac testing. As a test for occult bleeding in determining serious pathology, the guaiac card has a sensitivity of 44% to 75% and a specificity of 85%. As a screening tool, it has received mixed blessings, being promoted by the American Cancer Society and National Cancer Institute, but with insufficient evidence to recommend for or against by the US Preventive Services Task Force.
F. Colonoscopy. The diagnostic procedure of choice to visualize the entire colon. It allows only one bowel preparation and has identification rates of 74% to 82% of lower GI bleeding sources (5). The sensitivity of this examination approaches 98%.
G. Nuclear scintigraphy. 99mTechnetium-labeled red blood cells detects occult bleeding sources when the above-mentioned methods fail. Sensitivity ranges from 80% to 98% in the colon with specificity of 41% to 97% (5).
H. Mesenteric angiography uses a transfemoral placement to selectively evaluate the superior mesenteric, inferior mesenteric, and celiac axis. The sensitivity is 40% to 86% with a complication rate of 2% (5). Treatment interventions include arterial infusion of vasopressin and embolization with coil springs or gel foam.
I. Enteroscopy. Small bowel enteroscopy uses a special enteroscope or pediatric colonoscope. This scope is passed orally and has a diagnostic yield of 25% (5).
Diagnostic assessment
The answers provided in the patient’s history and physical examination are important to risk stratify this common problem. If a workup is believed necessary to deal with diagnostic uncertainty, then the entire colon should be visualized. This approach should consist of a digital rectal examination, anoscopy, rigid or flexible sigmoidoscopy, and the use of air contrast barium enema as deemed necessary. Alternatively, exploration by colonoscopy can be used, based on the provider’s discretion. The latter makes most sense as two bowel preparations can be reduced to one with enhanced patient comfort. Further workup, including nuclear scintigraphy, mesenteric angiography, enteroscopy, and referral to a surgeon or a gastroenterologist, depends on the clinical situation and seriousness of the bleed encountered. Serious pathology occurs in approximately 25% of rectal bleeding patients with 6.5% to 10% having cancer, 13% to 25% having polyps, and 4% to 11% having inflammatory bowel disease (1,2). Ten year follow-up of patients with benign anorectal disease or no evident cause of bleeding found no difference in the incidence of cancer compared with similarly aged cohort in the general population (1).
References
1. Helfant M, Marton KI, Zimmer-Gembeck MJ, Sax HC. History of visible rectal bleeding in a primary care population: initial assessment and 10-year follow-up. JAMA 1997;277(1):44–48.
2. Talley NJ, Jones M. Self reported rectal bleeding in a United States community: prevalence, risk factors, and health care seeking. Am J Gastroenterol 1998;93:
2179–2183.
3. Thompson M, Prytherah D. Rectal bleeding: when is it right to refer. Practitioner 1996;240:198–200.
4. Colletti RB, Compton CC. Weekly clinicopathological exercises: case 7-1997. A 14-year-old girl with recurrent painless rectal bleeding. N Engl J Med 1997;336(9):
641–648.
5. Vernava AM, Moore BA, Longo WE, Johnson FE. Lower gastrointestinal bleeding. Dis Colon Rectum 1997;40:846–858.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Purpura/Petechiae/Excessive Bleeding:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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:
DIagnostic Approach
(Field Guide to Bedside Diagnosis)
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:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Gum bleeding:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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 the absence of any teeth.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Gastrointestinal Bleeding:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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 areAgeClinical findings (e.g., vomiting,diarrhea, fever, constipation, abdominal pain, hepatomegaly, splenomegaly,abdominal distension, weight loss, and jaundice)History of aspirin, NSAID, or alcoholingestionPresence 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 CrohndiseaseSelective 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:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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.
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: 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.
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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.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
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