Monday, 2 December 2013

Hemorrhaging - Hemoptysis - The Managements

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.
Hemoptysis
 Hemoptysis is defined as a condition of coughing up blood from the bronchi, larynx, trachea, or lungs.
Managements
Researchers at the University of Wisconsin Medical School, Milwaukee, in the study of diagnosis and management of Hemoptysis, indicated that patient's history should help determine the amount of blood and differentiate between hemoptysis, pseudohemoptysis, and hematemesis. A focused physical examination can lead to the diagnosis in most cases. In children, lower respiratory tract infection and foreign body aspiration are common causes. In adults, bronchitis, bronchogenic carcinoma, and pneumonia are the major causes. Chest radiographs often aid in diagnosis and assist in using two complementary diagnostic procedures, fiberoptic bronchoscopy and high-resolution computed tomography, which are useful in difficult cases and when malignancy is suspected. The goals of management are threefold: bleeding cessation, aspiration prevention, and treatment of the underlying cause. Mild hemoptysis often is caused by an infection that can be managed on an outpatient basis with dose monitoring. If hemoptysis persists, consulting with a pulmonologist should be considered. Patients with risk factors for malignancy or recurrent hemoptysis also require further evaluation with fiberoptic bronchoscopy or high-resolution computed tomography(11). Other researchers suggested that the etiology of hemoptysis is best categorized from the various system or site of bleeding. The management of hemoptysis begins with an initial assessment of gas exchange and hemodynamic stability followed by an identification of the cause by means of fiberoptic bronchoscopy, and chest imaging studies to attain cessation of bleeding and to prevent future recurrence(12).
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Sources
(11) http://www.ncbi.nlm.nih.gov/pubmed/16225028
(12) http://www.ncbi.nlm.nih.gov/pubmed/20043609 

Hemorrhaging - Hemoptysis - The Diagnosis

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.
Hemoptysis
 Hemoptysis is defined as a condition of coughing up blood from the bronchi, larynx, trachea, or lungs.
Diagnosis 
3.1. Bronchoscopy
Bronchoscopy is a diagnostic technique to visualize inside the airway with insertion of bronchoscope into the airways. In the study to evaluated the diagnostic accuracy of results from fiberoptic bronchoscopy (FOB) and high-resolution computed tomography (HRCT) in 126 patients at Gangnam Severance Hospital (Seoul, Korea) who were suspected of having pulmonary tuberculosis (PTB), found that FOB is a useful tool in the rapid diagnosis of active PTB with a high sensitivity, specificity, PPV and NPV in sputum smear-negative PTB-suspected patients. HRCT improves the sensitivity of FOB when used in combination with FOB in sputum smear-negative patients suspected of having PTB(10).

3.2. Laryngoscopy
Laryngoscopy is a medical procedure to look at the back of the throat, including the voice box (larynx) and vocal cords.
 
3.3. Lung biopsy
Lung biopsy is the removal of a sample from the lung tissue through the wall of your chest for examination.
 
3.4. Mediastinoscopy
Mediastinoscopy is a surgical examination of the inside of the upper chest between and in front of the lung,, if your doctor suspected that the  Hemoptysis is caused by lung cancer.

3.5. Spirometry
Spirometry is test to measure the pulmonary function, including the volume and flow of air that can be inhaled and exhaled.

3.6. Tonsillectomy
Tonsillectomy is a surgical procedure to remove the tonsils from either side of the tonsillar fossa, if they are the cause of Hemoptysis.

3.7. Upper airway biopsy
It is a surgical removal of a sample from the upper airway (nose, mouth, throat) for examination.

3.8. Etc. 
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Sources
(10) http://www.ncbi.nlm.nih.gov/pubmed/22726571

Hemorrhaging - Hemoptysis - The Causes

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.
Hemoptysis
 Hemoptysis is defined as a condition of coughing up blood from the bronchi, larynx, trachea, or lungs.
Causes
2.1. Cystic fibrosis (23%), bronchiectasis (13%), tuberculosis sequelae (8%), chronic obstructive pulmonary disease (COPD)(6%)
According to the study of researchers at the Università degli Studi di Milano. Ospedale San Paolo, the causes of haemoptysis was as follows: cystic fibrosis (23%), bronchiectasis (13%), tuberculosis sequelae (8%), chronic obstructive pulmonary disease (COPD) (6%) and no apparent cause (21%). Major complications were recorded in 3/477 (0.6%): stroke (n=1), transient ischaemic attack (TIA) (n=1) and transient quadriplegia (n=1). Minor complications were recorded in 143/477 (30%): chest pain 86/143 (60%) and dysphagia 29/143 (20%). During a mean follow-up period of 14 (8-36) months, haemoptysis recurrence was observed in 42/110 cases (38%) of cystic fibrosis and in 77/367 cases of other diseases (21%)(2).

2.2. Thrombasthenia is a rare disorder of blood platelets, which results in easy bruising and nosebleeds.

2.3. Blood clot in the lung 
Blood clot in the lung due to Venous thrombosis, as a result of  blood clot formed in a vein breaks off and transported to the right side of the heart into the lungs. must be coughed out for the normal function of the lung. There is a report of a young woman diagnosed as having microscopic polyangiitis (MPO) presenting with diffuse alveolar hemorrhage (DAH). DAH is a rare, but life-threatening disorder. The patients presented with dyspnea, cough, hemoptysis (not constant). The radiographic features are very characteristic and reveal the signs of diffuse, bilateral alveolar filling in chest HRCT especially in middle and lower zones(3).

2.4. Bronchiectasis and Tuberculosis
There is a report of a 39-year-old woman presented with chronic cough, haemoptysis and hoarseness of voice. She had left recurrent laryngeal nerve palsy and high inflammatory markers on investigation. CT thorax revealed aortic wall thickening and traction bronchiectasis. 2 D echocardiogram revealed grade 1 aortic regurgitation compatible with aortitis(4). Other researchers in the study of 154 patients admitted for life-threatening hemoptysis (LTH) over 3 consecutive years. Bronchoscopy and arteriography procedures were performed, as prescribed by the attending physician. Patient evolution was followed 5 years post-event, wrote that teading causes of life-threatening hemoptysis (LTH) were bronchiectasis and tuberculosis. While bronchoscopy during a hemoptysis episode was effective in identifying the source of the bleeding, artery embolization was more effective in stabilizing the patient both at the short and long term(4a).

2.5.  Pulmonary edema 
Pulmonary edema has been reported in SCUBA divers, apnea divers, and long-distance swimmers. Researchers at the  University Boulevard, in the study of Immersion pulmonary edema in female triathletes, showed that Contributing factors include hemodynamic changes due to water immersion, cold exposure, and exertion which elevate cardiac output, causing pulmonary capillary stress failure, resulting in extravasation of fluid into the airspace of the lung(5).

2.6. Cystic fibrosis 
Cystic fibrosis (CF) is a recessive genetic disease characterized by dehydration of the airway surface liquid and impaired mucociliary clearance and Hemoptysis and pneumothorax are complications commonly reported in patients with cystic fibrosis(6).

2. 7. Esophageal and Lung cancer
If the tumor in the lung and Esophagus cause the break off of the blood vessels, it can cause coughing of blood to protect the respiratory system.

2.8. Esophageal and/or laryngeal candidiasis
Esophageal and/or laryngeal candidiasis can cause signs and symptoms of  hemoptysis(7).

2.9. Pneumonia 
There is a report of a 37-year-old man with hemoptysis, fever, and shortness of breath. The clinical and laboratory examinations revealed that the patient had pseudohemoptysis due to S. marcescens pneumonia, on an immunocompromised pattern, because of the coexistence of sarcoidosis, accoring to the study by General Hospital, Aristotle University of Thessaloniki(8).

2.10. Others
In the study of Hemoptysis: an uncommun case by Serviços de Medicina Interna e de Pneumologia, Hospital de Sousa Martin, researchers indicated that hemoptysis is a symptom that suggests a variety of pathologies that can be more or less benign and even fatal, a life threatening for the person who suffers it. Between the most common causes we have bronchitis, bronchiectasis and bronchopulmonary neoplasia. Less frequent causes are: Goodpasture's syndrome, Wegener's granulomatosis, systemic lupus erythematosus, between others(9). 
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Sources
(1) http://www.ncbi.nlm.nih.gov/pubmed/22791000
(2) http://www.nejm.org/doi/full/10.1056/NEJMcpc0708507
(3) http://www.ncbi.nlm.nih.gov/pubmed/22335144
(4) http://www.ncbi.nlm.nih.gov/pubmed/22905814
(4a) http://www.ncbi.nlm.nih.gov/pubmed/22704276
(5) http://www.ncbi.nlm.nih.gov/pubmed/21660230
(6) http://www.ncbi.nlm.nih.gov/pubmed/20675678
(7) http://www.ncbi.nlm.nih.gov/pubmed/7422428
(8) http://www.ncbi.nlm.nih.gov/pubmed/21941452
(9) http://www.ncbi.nlm.nih.gov/pubmed/18282444

Hemorrhaging - Hemoptysis - The Symptoms

 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.
Hemoptysis
 Hemoptysis is defined as a condition of coughing up blood from the bronchi, larynx, trachea, or lungs.

1. Symptoms
Symptoms of Hemoptysis can be as a result of bronchial infection or a sign of a more serious illness such as tumor and cancer
1.1 Chest pain
Chest pain us one of most common dymptoms of patient with Hemoptysism. It may be a result of the diseases have affected the nerve cells  in the check area, including infection and tumor.

1.2. Dyspnea or shortness of breath (SOB)
This mau be the result of the disease has affected the lung in the absorption of oxygen, including tumor and infectiob There is a report of a 26-year-old Chinese man, presenting with hemoptysis in the emergency room, was hospitalized because of dyspnea. The X-ray examination revealed a tumor in the right chest cavity(1).

1.3. Fever
As a result of infection of the respiratory system.

1.4. Nausea and Vomiting
It is a result of bloods accumulation in the chest area needed to be cough out for the better function of the respiratory system.

1.5. Tachypnea (rapid breathing)
Top provide enough oxygen for the body



1.7. Etc. 
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Hemorrhaging: Hematemesis - Management and treatments

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.
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.
Management and treatments
2.1. Severe blood blood and life threatening
In the study of treatment of hematemesis and hematochezia in elderly patients by Department of Internal Medicine (III) Asahikawa Medical College, hematemesis and hematochezia (melena) in elderly patients are serious symptoms which should be carefully handled since they can lead to death without suitable treatment. In elderly patients the advance of arteriosclerotic changes throughout the body decreases blood flow and function in various organs. When these arteriosclerotic changes become prominent in the gastric vascular structure, bleeding from gastric ulcers tends to easily occur and it can be difficult to stop. A large amount of bleeding can cause irreversible shock due to the decreased cardiopulmonary function, and diminished hepatorenal capacity would also be a decisive factor in determining the outcome of the state of shock(11). In this case, Fluids and/or blood is administered, preferably by central venous catheter, and the patient is prepared for emergency endoscopy, which is typically done in theatres. Surgical opinion is usually sought in case the source of bleeding cannot be identified endoscopically, and laparotomy is necessary. Securing the airway is a top priority in hematemesis patients, especially those with a disturbed conscious level (hepatic encephalopathy in oesophageal varices patient.) A cuffed endotracheal tube could be a life saving choice(12).

2.2. Blood loss but not life threatening
In this case, certain medication such as Proton-pump inhibitors (PPIs) to reduce gastric acid production and blood transfusion depending to levels of hemoglobin, no eating until endoscopy can be arranged.
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Sources 
(12) http://en.wikipedia.org/wiki/Hematemesis

Hemorrhaging: Hematemesis - The Symptoms

 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.
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.
Symptoms
In the study of one hundred and seven consecutive patients with hematemesis and/or melena and a diagnosis of duodenal, gastric, or esophageal ulcers were interviewed immediately before or after endoscopy about the use of non-steroid anti-inflammatory drugs (NSAIDs) and symptoms before the hemorrhage, showed that if the patients admitted no symptoms of abdominal pain or discomfort, nausea, vomiting, or heartburn, they were classified as having no ulcer symptoms before the hemorrhage. Patients who had not taken NSAIDs during the last 48 h before the hemorrhage were classified as not having taken NSAIDs. Significantly fewer patients had ulcer symptoms in the group that had used NSAIDs than in the other group (p less than 0.01)(11).
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Sources
(11) http://www.ncbi.nlm.nih.gov/pubmed/16225028  

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

Class


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

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

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


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

1.14. Etc.
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Sources
(1a) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1065003/table/T1/
(1) http://www.ncbi.nlm.nih.gov/pubmed/7222121
(2) http://www.ncbi.nlm.nih.gov/pubmed/7611215
(3) http://www.ncbi.nlm.nih.gov/pubmed/1988788
(4) http://www.ncbi.nlm.nih.gov/pubmed/310725
(5) http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=229
(6) http://www.ncbi.nlm.nih.gov/pubmed/22140409
(7) http://www.ncbi.nlm.nih.gov/pubmed/4058204
(8) http://www.ncbi.nlm.nih.gov/pubmed/1764626
(9) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1411755/pdf/gut00657-0069.pdf
(10) http://www.ncbi.nlm.nih.gov/pubmed/22537571