INTERNAL BLEEDING

What is internal bleeding?

Internal bleeding is blood loss occurring within your body. Because it occurs inside your body, internal bleeding may go unnoticed initially. If the bleeding is rapid, enough blood may build up to press on internal structures or to form a bulge or discoloration under your skin. Severe internal bleeding can cause shock and loss of consciousness.

Internal bleeding occurs when damage to an artery or vein allows blood to escape the circulatory system and collect inside the body. The amount of bleeding depends upon the amount of damage to an organ and the blood vessels that supply it, as well as the body's ability to repair breaks in the walls of the blood vessels. The repair mechanisms available include both the blood clotting system and the ability of blood vessels to go into spasm to decrease blood flow to an injured area.

Patients who take anti-clotting medication such as warfarin (Coumadin), clopidogrel (Plavix), heparin, or aspirin are more prone to bleeding than people who do not take these medications. These individuals may experience significant bleeding even with relatively minor injury or illness, and the risk of bleeding needs to be balanced against the benefits of taking the medication.

Some people have genetic or inborn errors of the blood clotting system. Minor injuries may cause major bleeding in these cases. Hemophilia and von Willebrand disease are two examples.



What are the Causes of internal bleeding


Cancer 

Bleeding is common in many types of cancer. Sometimes the bleeding is obvious, but more often, cancer-related bleeding is internal, with perhaps some external manifestations. For example, blood in the stool can indicate cancer of the colon or rectum, while vaginal bleeding could suggest cancer of the cervix, uterus, or ovary. Blood in the urine may signify kidney or bladder cancer. One sign of stomach cancer is vomiting blood; esophageal cancer can also produce vomiting or spitting up blood.


Cirrhosis


In this disease, which is most commonly caused by alcohol abuse, scar tissue forms in the liver and obstructs the flow of blood. In the advanced stages of cirrhosis, there may be heavy bleeding into the esophagus.


Colon polyps


Colon polyps are small, grape-like growths that form clusters inside the large intestine. Some are hereditary (familial polyposis) and have a high probability for becoming cancerous. More often, they are harmless; both types, however, are a common cause of hidden intestinal bleeding.


Diverticulosis


In diverticulosis, small out­pouches form along weakened segments of the colon wall. Sometimes these pouch­es become impacted with fecal material, causing inflammation. In severe cases, one or more of these outpouches may rupture, causing bleeding and spilling the colon contents into the abdominal cavity. This can lead to life-threatening peritonitis.


Gastric disorders


Gastrointestinal bleeding may be caused by a variety of disorders, as well as by certain medications. Aspirin, for example, can be the culprit if taken often and in high doses. Gastrointestinal bleeding ranges from mild to severe, and in conditions such as a peptic ulcer, it can cause massive hemorrhage and death if treatment is delayed. If massive bleeding occurs, other symptoms may include pain, heavy perspiration, vomiting blood, bloody stools, and shock.


Hemophilia


This is an inborn defect of blood coagulation. It affects only males, although women carry the causative gene. Children who have it often bleed into the joints, resulting in joint pain, swelling and deformity. Even a trivial injury can result in severe internal and external bleeding.


Leukemia


Some forms of leukemia can cause internal bleeding. Other symptoms may include high fever, joint pain, fatigue, pallor, and abnormal blood counts.


Marfan's syndrome


This inherited disorder can cause weakness of the aorta, the largest artery that carries blood from the heart for distribution to all parts of the body. Severe, internal bleeding can occur if an aneurysm develops and ruptures.


Miscarriage and menstrual disorders


Severe vaginal bleeding may occur during a miscarriage. It also may be a sign of approaching menopause or failure to ovulate. Vaginal bleeding that is unrelated to pregnancy or menstruation is a common sign of cancer.


Vascular disorders


These are disorders of the blood vessels in which inter­nal bleeding is a likely symptom. Purpura, in which blood vessels are fragile and the person bruises easily, is one of the most common of these disorders. There may also be fever and joint pain

What other symptoms might occur with internal bleeding?

Symptoms accompanying internal bleeding vary based on the location and speed of blood loss. Pain may or may not be present. Rapid bleeding can quickly cause weakness, dizziness, shock and unconsciousness. Slower bleeding may ultimately cause anemia, with the gradual onset of tiredness, weakness, shortness of breath, and pallor. Bleeding into the gastrointestinal or urinary tract can cause blood in the stool, vomit or urine.

Common symptoms that may occur with internal bleeding in the head

Internal bleeding in the head may accompany other symptoms including:

• Change in mental status
• Confusion
• Garbled or slurred speech or inability to speak
• Headache
• Loss of vision or changes in vision
• Numbness or tingling
• Paralysis
• Weakness (loss of strength)

Common symptoms that may occur along with internal bleeding in the chest or abdomen

Internal bleeding in the chest or abdomen may accompany other symptoms including:

• Abdominal, pelvic, or lower back pain that can be severe
• Abdominal swelling, distension or bloating
• Bruising around the navel or of the flanks
• Chest pain
• Coughing up blood (hemoptysis)
• Difficulty breathing
• Dizziness or lightheadedness
• Enlarged liver or spleen
• Shortness of breath

Common symptoms that may occur along with bleeding into the muscles or joints

Internal bleeding into the muscles or joints may accompany other symptoms including:

• Bone or joint deformity
• Loss of sensation
• Pain
• Reduced mobility (range of motion)
• Swelling, redness or warmth

Other symptoms that may occur along with internal bleeding

Internal bleeding at other sites may accompany other symptoms including:

• Abdominal pain or cramping
• Bloody or pink-colored urine (hematuria)
• Bloody stool (blood may be red, black, or tarry in texture)
• Hematoma (collection of blood in body tissues)
• Pain
• Vomiting blood or black material (resembling coffee grounds)

Serious symptoms that might indicate a life-threatening condition

In some cases, internal bleeding may be a symptom of a life-threatening condition that should be immediately evaluated in an emergency setting. Seek immediate medical care if you, or someone you are with, have any of these life-threatening symptoms including:

• Bleeding while pregnant
• Bluish coloration of the lips or fingernails
• Change in level of consciousness or alertness, such as passing out or unresponsiveness
• Change in mental status or sudden behavior change, such as confusion, delirium, lethargy, hallucinations and delusions
• Chest pain, chest tightness, chest pressure, palpitations
• Garbled or slurred speech or inability to speak
• Not producing any urine, or an infant who does not produce the usual amount of wet diapers
• Paralysis or inability to move a body part
• Rapid heart rate (tachycardia)
• Respiratory or breathing problems, such as shortness of breath, difficulty breathing, labored breathing, wheezing, not breathing
• Severe pain
• Vomiting blood, rectal bleeding, or bloody stool

How is internal bleeding diagnosed?

The diagnosis for internal bleeding begins with the doctor taking a history and performing a physical examination on the patient. The situation and the source of the bleeding will focus the testing strategy on the part of the body that may be involved with the bleeding. Sometimes the direction of diagnosis is self evident; a motor vehicle crash victim who complains of abdominal pain will have attention directed to the abdomen. Sometimes it is less evident. A confused patient may have issues with bleeding in the brain, or may be so anemic (decreased red blood cell count) from blood loss elsewhere, that the brain is not getting enough oxygen and nutrients to function properly.

Blood tests may include a complete blood count (CBC) or hemogram to access for anemia and abnormal platelet count. INR (international normalized ratio) and PTT (partial thromboplastin time, a blood test that measures how long it takes for blood to clot) are blood clotting studies that may be measured to screen for abnormal clotting function. Depending upon the situation, the hospital blood banking system may be alerted to begin the process of crossmatching blood products for potential transfusion.

Diagnostic tests such as X-rays, Doppler ultrasound, and CT scan may be used depending upon the underlying medical problem associated with internal bleeding.

Computerized tomography (CT scan) is the primary tool used in emergency situations to access for bleeding or swelling in the brain. In a small fraction of patients who have bleeding from a ruptured cerebral aneurysm (a blood vessel that leaks in the brain), the CT will initially be normal and a lumbar puncture may be performed to help make the diagnosis.

CT scan is also one of the tests that can be performed to access for bleeding within the abdomen and chest. It is especially helpful in trauma to look for bleeding from the solid organs of the abdomen like the liver, spleen, and kidney. It is ideal for evaluating the retroperitoneal space for bleeding and can also evaluate fractures of the pelvis and spine.

In cases of potential bleeding from a major blood vessel, CT angiography may be considered to look for a specific blood vessel that is bleeding.

Ultrasound may be used to look for sources of bleeding, most often where there is an obstetric or gynecologic source of bleeding.

Endoscopy, colonoscopy, and anoscopy are used to look for sources of bleeding in the gastrointestinal tract. Using a flexible scope with an attached camera, a gastroenterologist may look into the stomach and intestine, rectum, and colon to find the source of bleeding. Using the same instrument, cautery (electricity used to coagulate or burn a blood vessel) can stop the bleeding if the source is found

How is internal bleeding treated?

The initial treatment plan of any patient with internal bleeding begins with assessing the patient's stability and making certain the ABCs are well maintained. This includes making certain the patient's:

• Airway is open,
  
  
• that the patient is Breathing, and
  
  
• that there is adequate Circulation, meaning good pulse and blood pressure.

The definitive treatment of internal bleeding depends upon where the bleeding is occuring, the individual situation, and the stability of the patient. The basic goals include identifying and stopping the source of bleeding and repairing any damage that the bleeding may have caused.

What are the complications of internal bleeding?

Depending upon where it occurs, if not recognized, internal bleeding may cause organ failure, shock, and death. For example:

• If there is uncontrolled bleeding in the chest or abdomen, the body may lose enough circulating red blood cells to compromise oxygen delivery to cells in the body. This situation is called shock. If the bleeding is not stopped and if fluid resuscitation and perhaps blood transfusion are not provided, the patient may die.
  
  
• Internal bleeding in the brain may cause minimal damage, but if there is enough to cause increased pressure or if the bleeding increases, enough brain tissue may be damaged to cause stroke-like symptoms, coma, and death.

How can we prevent or take precautions?

Internal bleeding covers many organ systems and situations. Disease and injury prevention is the basis of maintaining a healthy lifestyle.

Key to prevention include preventing heart attack and stroke by controlling high blood pressure, diabetes and high cholesterol.

Injury prevention includes wearing appropriate safety equipment for the activity involved and avoiding risky behaviors like drinking and driving.

Preventing alcohol-related diseases can help prevent a significant cause of internal bleeding.

Individuals taking medication that predispose them to internal (and external) bleeding should take extra precautions to avoid any trauma; moreover, they should continue to get routine blood tests (INR, PT, CBC's) to see if they are appropriately medicated and assure they are not bleeding internally

Internal Bleeding At A Glance

• Internal bleeding may occur in many areas of the body and may cause significant local pain. If enough bleeding occurs, signs of shock may be apparent.
  
  
• Bleeding is a recognized complication of anti-coagulation medications such as aspirin, clopidogrel (Plavix), warfarin (Warfarin), and heparin. The benefits of these medications need to be balanced against the risk of bleeding.
  
  
• Bleeding is never normal in pregnancy.
  
  
• If internal bleeding is suspected, it is important to seek medical care