Monday, 2 December 2013

Hemorrhaging - The Classification and Types

 Hemorrhaging is also known as bleeding or abnormal bleeding as a result of blood loss due to internal.external leaking from blood vessels or through the skin.

 I. Classifications of Hemorrhaging
According to the classification from the American College of Surgeons' Advanced Trauma Life Support (ATLS), Hemorrhaging is divided into 4 classes, depending to the volumes of blood loss and other factors

Classification of hemorrhage


Blood loss (ml)<750750–15001500–2000>2000
Blood loss (%)<15%15–30%30–40%>40%
Pulse rate (beats/min)<100>100>120>140
Blood pressureNormalDecreasedDecreasedDecreased
Respiratory rate (breaths/min)14–2020–3030–40>35
Urine output (ml/hour)>3020–305–15Negligible
CNS symptomsNormalAnxiousConfusedLethargic
Modified from Committee on Trauma. CNS = central nervous system(1a).

II.  Types of hemorrhaging 
A. Mouth
A.1. Hematemesis 
Hematemesis is defined as a condition of either upper gastrointestinal tract fresh blood vomiting or altered blood vomiting due to acid on the blood.
1. Causes
There are many causes of  Hematemesis, including 
1.1. Mallory-Weiss syndrome: 
There is  records of 29 patients with Mallory-Weiss tears diagnosed by endoscopy. Ingestion of alcohol was a chief cause of bleeding. Single tears were the largest in number and 68% of the lacerations were seen just distal to the esophago-cardial junction(1).

1.2. Irritation of the lining of the esophagus or stomach 
Prolonged inflammation and allergic reaction or erosion as a result of irritant(s) can lead to damage to the cells of the lining of the esophagus or stomach.

1.3. Vomiting as a result of bleeding of the oral cavity, nose or throat
Vomiting of blood due to bleeding of the oral cavity, nose or throat

1.4. Vascular malfunctions
Vascular malformations, also known as congenital vascular malformations (CVMs) are defined as a condition of abnormalities in the formation of blood vessels of the gastrointestinal tract, including ulcer,  bleeding due dilated submucosal veins in the stomach and intestines.

1.5. Tumors of the stomach or esophagus
Abnormal cell growth such as tumors of the stomach or esophagus can cause internal bleeding as a result of tumor causes of breaking off the blood veins and capillaries.

1.6. Acute and chronic radiation syndrome
a. Acute radiation syndrome is a defined as a condition of radiation poisoning as a result of the exposure to high amounts of ionizing radiation that affects gastrointestinal track. leading to  infection and bleeding.
b. Chronic radiation syndrome
there is a  report describes a 73-yr-old man who developed uncontrollable hematemesis due to a primary aortoduodenal fistula in the fourth portion of the duodenum approximately 20 yr after radiotherapy and para-aortic lymph node dissection for seminoma(2).

1.7. Influenza virus
There is a report of Seven children who presented during the influenza A(H1N1) epidemic of 1988 are described. After a typical influenzal illness, they developed haematemesis of varying severity. Endoscopy revealed haemorrhagic gastritis(3).

1.8.The viral haemorrhagic fevers
There are reviews of the viral haemorrhagic fevers that infect man, namely smallpox, chikungunya fever, dengue fever, Rift Valley fever, yellow fever, Crimean haemorrhagic fever, Kyasanur Forest disease, Omsk haemorrhagic fever, Argentinian haemorrhagic fever (Junin virus), Bolivian haemorrhagic fever (Machupo virus), Lassa fever, haemorrhagic fever with renal syndrome, and Marburg and Ebola virus diseases(4).

1.9. Gastroenteritis 
Gastroenteritis is defined as a condition of inflammation of the upper gastrointestinal track of that can lead to diarrhea, vomiting, and abdominal pain and cramping(5). In severe case, it can cause blood vomiting.

1.9. Gastritis 
Gastritis is defined as a condition of an inflammation of the lining of the stomach as a result of excessive alcohol drinking and medication intake such as aspirin, ibuprofen, etc. over a prolonged period of time. there is a report of the case of 40-year-old woman who presented 6 weeks after intentional ingestion of hydrochloric acid with abdominal pain and haematemesis. Gastroscopy showed a necrosed and ulcerated stomach with pyloric stricture(6).

1.10. Peptic ulcer 
Dr. Thon K, and Dr.Röher the study of [Hemorrhaging peptic ulcer--Therapy? When? Which?] indicated that a close correlation between the risk and incidence of recurrent bleeding and the primary bleeding status during emergency endoscopy let us to design a new concept of a more aggressive surgical strategy. The dominating criteria for choice of treatment based on instant endoscopical classification of bleeding type and activity(7).

1.11. Chronic liver disease
Chronic liver disease and its sequelae (often long-term results of viral hepatitis) are commonplace. Haematemesis and hepatocellular failure are usually very difficult to manage due to a lack of sophisticated support techniques in developing countries. Invasive hepatic amoebiasis usually responds well to medical management; however, spontaneous perforation can occur and the consequences of this are serious(8).

1.12. Intestinal Schistosomiasis 
Intestinal schistosomiasis, caused by the trematodes Schistosoma mansoni and S. japonicum, is found over a wide area of Africa, the Middle East, in the Orient, South America, and parts of the Caribbean. In the article of Progress report Intestinal schistosomiasis, showed that Intestinal Schistosomiasis can lead to liver diseases and Haematological Changes, as Patients suffering from intestinal schistosomiasis are frequently anaemic. In Puerto Rico Ramos-Morales14 found that 58 % of 1,547 untreated patients had a haemoglobin concentration of less than 13 g/100 ml with 4% less than 1Og/100 ml. Seventy-six per cent of these patients were aged 15 years or less and some had hookworm infection which could have contributed to blood loss(9).

1.13. History of Smoking 
In a study of A total of 240 patients representing 18.7% of all patients (i.e. 1292) who had fibreoptic upper GI endoscopy during the study period were studied. Males outnumbered female by a ratio of 2.1:1. Their median age was 37 years and most of patients (60.0%) were aged 40 years and below. The vast majority of the patients (80.4%) presented with haematemesis alone followed by malaena alone in 9.2% of cases. The use of non-steroidal anti-inflammatory drugs, alcohol and smoking prior to the onset of bleeding was recorded in 7.9%, 51.7% and 38.3% of cases respectively. Previous history of peptic ulcer disease was reported in 22(9.2%) patients. Nine (3.8%) patients were HIV positive. The source of bleeding was accurately identified in 97.7% of patients(10).

1.14. Etc.
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