Hemorrhaging: Hematochezia (rectal bleeding) - The Risk Factors

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.
Hematochezia (rectal bleeding)
Hematochezia is defined as a condition of the passage of bright red, bloody stool. In most cases it is an indication of hemorrhoids (swollen veins in and around the rectum) or diverticulitis, a common digestive disease particularly found in the large intestine, as a result of infection or inflammation.
Risk Factors
3.1. Aging
Risk of rectal bleeding increase with age as  the result of weakened intestinal blood vessels. In the study of the group consisted of 102 patients (50 years of age or less)  with a flexible endoscope and an anoscopethat presented for evaluation of rectal bleeding, showed that six patients had colitis; all but one of these patients were less than 40 years of age. Flexible endoscopy and anoscopy provide complimentary information in middle-aged adults with rectal bleeding(10)

3.2. Family history of gastrointestinal disease
People with the family of ulcerative colitis and Crohn’s disease, are at increased risk of rectal bleeding

3.3. Others, according to American Journal of Gastroenterology (1998) 93, 2179–2183; doi:10.1111/j.1572-0241.1998.00530.x

FROM: Self-reported rectal bleeding in a United States community: prevalence, risk factors, and health care seeking by Nicholas J Talley and Michael Jones(11)

Table 1. Association of Rectal Bleeding With Potential Risk Factors Based on Univariate Logistic Regression

Figure and tables index

	Any Rectal Bleeding		Blood Coating the Stools		Blood on Toilet Paper		Dark Blood Viewed in Stools
	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI
Age 45 yr	0.54*	0.41–0.72	1.19	0.67–2.12	1.64	0.43–6.23	0.60	0.29–1.23
Sex (male)	0.95	0.72–1.26	0.56	0.32–0.98	1.30	0.40–4.22	1.10	0.58–2.11
Marital status	0.82	0.55–1.22	3.0*	1.11–8.11	3.26	0.92–11.51	0.43	0.19–0.98
Employment (yes vs no)	0.55	0.31–0.96	0.59	0.16–2.18	0.55	0.06–4.72	1.67	0.50–5.63
Education (< HS vs HS + tertiary)	1.19	0.93–1.52	1.14	0.69–1.87	2.46	0.86–7.06	0.33	0.18–0.62
Aspirin (none, some)	1.08	0.82–1.42	1.06	0.61–1.84	1.52	0.47–4.94	0.75	0.39–1.44
Ulcer history (yes)	1.12	0.72–2.02	1.61	0.62–4.18	0.42	0.09–2.09	1.47	0.50–4.32
Gastric surgery	1.58	0.89–2.79	1.64	0.55–4.92	0.29	0.06–1.48	2.36	0.75–7.41
IBS (yes)	1.48*	1.04–2.10	1.06	0.54–2.05	1.07	0.28–4.15	1.65	0.78–3.50
Constipation (yes)	3.09*	2.33–4.10	1.51	0.86–2.67	0.24	0.05–1.14	2.30*	1.14–4.65
Diarrhea (yes)	2.08*	1.51–2.85	0.71	0.38–1.33	2.08	0.44–9.75	4.12*	2.10–8.11
Urgency (yes)	1.55*	1.11–2.15	1.24	0.66–2.35	0.94	0.25–3.60	3.25*	1.68–6.48
Dyspepsia (yes)	1.31	0.83–2.04	1.48	0.63–3.47	0.59	0.12–2.86	1.29	0.49–3.45
Smoking (never vs current)	0.96	0.67–1.39	0.41	0.18–0.97	0.74	0.18–3.09	3.67*	1.65–8.12
Alcohol (0–6 vs 7 drinks wk)	1.34	0.92–1.93	1.02	0.49–2.11	0.55	0.14–2.15	3.51	1.67–7.38
Bowel surgery	1.03	0.60–1.76	1.17	0.42–3.30	0.81	0.10–6.73	1.36	0.42–4.42
Physician visits (bowel trouble)	5.26*	3.19–8.65	1.17	0.53–2.57	0.82	0.17–3.93	2.93*	1.30–6.61

^*  p < 0.05.
 HS = high school; IBS = irritable bowel syndrome; CI = confidence interval; OR = odds ratio.

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Sources
(10) http://www.ncbi.nlm.nih.gov/pubmed/7628276
(11) http://www.nature.com/ajg/journal/v93/n11/fig_tab/ajg1998500t1.html#figure-title 

Hemorrhaging: Hematochezia (rectal bleeding) - 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.
Hematochezia (rectal bleeding)
Hematochezia is defined as a condition of the passage of bright red, bloody stool. In most cases it is an indication of hemorrhoids (swollen veins in and around the rectum) or diverticulitis, a common digestive disease particularly found in the large intestine, as a result of infection or inflammation.
Causes
2.1. Ectopic pregnancy
There is a report of case of severe rectal bleeding due to an ectopic pregnancy in the wall of the cecum is reported. The usual preoperative studies for rectal bleeding were performed but did not yield a definitive diagnosis. At laparotomy the right side of the uterus was found to be adherent to the cecum(1).

2.2. Abdominal colic and major gastrointestinal haemorrhage
There is a report of a case of massive rectal bleeding resulting from the placental attachment of an abdominal pregnancy to the sigmoid colon is reported. Both mother and infant survived this rare complication which should be considered when abdominal colic and major gastrointestinal haemorrhage occur in a pregnant patient(2). Other researchers also report of a case of an unusual case of massive bleeding per rectum caused by erosion into the caecum of placental tissue from an ectopic pregnancy is presented. Despite its rarity, abdominal pregnancies may have to be considered in sexually active fertile women presenting with difficult torrential bleeding from the lower gastrointestinal tract(3).

2.3. Angiodysplastic lesions (vascular lesions of the gastrointestinal tract)
In the study of a single angiodysplasias demonstrated by preoperative angiography in four patients and the review of the literature on intestinal angiodysplastic lesions, found that the relative frequency of angiodysplasias in the right side of the colon is noted. Visceral angiography is an important investigation in cases where there is persistent or recurrent bleeding from the gastrointestinal tract, especially when barium studies and laparatomy have been negative(4).

2.4. Coagulation disorder 
In the study of Rectal bleeding, deep venous thrombosis, and coagulopathy in a patient with Klippel-Trénaunay syndrome, reserachers indicated that this report validates the use of endorectal resection for venous malformation of the rectum in patients with KTS and highlights the difficult balance of controlling bleeding by correction of a consumptive coagulopathy and the increased risk of thromboembolic complications(5).

2.5. Hemostatic disorders
In the report of a 79-year-old woman (weight, 69 kg) was hospitalized in a gastroenterology unit for severe rectal bleeding. She had been treated for 2 months with dabigatran etexilate 110 mg twice daily for chronic atrial fibrillation. On admission, her creatinine clearance (CrCl) was 20.7 mL/min/1.73 m(2), prothrombin time (PT) less than 10% (reference range 70-130%), and international normalized ratio (INR) 14.5 (venous blood). Eleven days after admission, hematologic and renal function were normalized and rectal bleeding stopped. An 84-year-old man (weight, 71 kg) was admitted for rectal bleeding with acute renal failure and dehydration that began while he was treated with dabigatran etexilate 110 mg twice daily for atrial fibrillation. On admission, CrCl was 33.5 mL/min/1.73 m(2), PT 13%, and INR 7.53 (venous blood). Dabigatran etexilate was stopped on admission. At the end of the hospitalization, CrCl was 66.5 mL/min/1.73 m(2), PT 54%, and INR 1.53. In both cases, an objective causality assessment revealed that those adverse reactions were probably related to dabigatran etexilate(6).

2.6. Colon cancer
It can be with or without pain. In the study of 604 patients and 22 (3.6%, 95% confidence interval [CI] = 2.0% to 5.2%) were diagnosed with colorectal cancer. Significant predictors of colorectal cancer were found to be age (<50 years: odds ratio [OR] = 1; 50-69 years: OR = 5.1, 95% CI = 1.4 to 18.6; > or = 70 years: OR = 8.2, 95% CI = 2.1 to 31.8) and blood mixed with the stool (Likelihood ratio [LR] 1.5; adjusted OR = 3.8; 95% CI = 1.4 to 10.5). Presence of haemorrhoids associated with bright red bleeding not mixed with stool reduced the likelihood of cancer (OR = 0.4, 95% CI = 0.1 to 1.2) but did not eliminate it--a cancer was present in 2% of patients with these symptoms(7).

2.7. Colorectal polyps
In the conduction of two studies, the first in 1989, the second in 1991, in which we invited Danish general practitioners to register 3-4 patients aged 40 and over presenting with rectal bleeding, researchers found that study 1 among 208 patients aged 40 and over and presenting with a first episode of rectal bleeding, colorectal cancer and polyps were present in 15.4 and 7.7%, respectively. In Study 2 among 209 patients aged 40 and over and presenting with overt rectal bleeding, 156 reported a first bleeding episode or a change in their usual bleeding pattern, and in this group colorectal cancer and polyps were diagnosed in 14.1 and 11.5%, respectively. In the group with unchanged bleeding the cancer polyp prevalence was 6.7% (P < 0.05). The patients in both studies were followed through a yearly letter to the GP for at least 32 and 22 months, respectively(8).

2.8. Hemorrhoids
There is a report of within a period of 18 months, 387 patients were referred to the Proctologic Service at the Chaim Sheba Medical Center because of recurrent rectal bleeding. Hemorrhoids were found in 194 of these patients and further investigation showed that 45 of the 194 patients (23.2%) had other coexisting colonic pathology (12 cancers, 28 polyps, 4 inflammatory bowel diseases and 1 angiodysplasia). Sixteen of 40 patients with diverticulosis and 13 of 30 patients with hemoglobin less than 11 g/dl had additional colonic pathology(9).

2.9. Etc. 
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Sources
(1) http://www.ncbi.nlm.nih.gov/pubmed/309659
(2) http://www.ncbi.nlm.nih.gov/pubmed/3875846  
(3) http://www.ncbi.nlm.nih.gov/pubmed/1295424
(4) http://www.ncbi.nlm.nih.gov/pubmed/4544790
(5) http://www.ncbi.nlm.nih.gov/pubmed/22424361
(6) http://www.ncbi.nlm.nih.gov/pubmed/22669799
(7) http://www.ncbi.nlm.nih.gov/pubmed/17007706
(8) http://www.ncbi.nlm.nih.gov/pubmed/8732328
(9) http://www.ncbi.nlm.nih.gov/pubmed/3872288

Hemorrhaging: Hematochezia (rectal bleeding) - 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.
Hematochezia (rectal bleeding)
Hematochezia is defined as a condition of the passage of bright red, bloody stool. In most cases it is an indication of hemorrhoids (swollen veins in and around the rectum) or diverticulitis, a common digestive disease particularly found in the large intestine, as a result of infection or inflammation.
Symptoms
1.1. Abdominal cramping and distention
In the some case the passing of large amount of  blood is accompanied with abdominal cramping and distention as a result of colitis (inflammation of the large intestine).

1.2. Constipation
It is a result of severe rectal pain.

1.3. Dizziness and Fatigue
These may be result of the influence of the blood loss causing not enough oxygen to be transported.

1.4. Fever
This can be a result of inflammation or infection of the large intestine.

 1.5. Body weakness
It is a result of not enough blood to transport nutrients and oxygen to the cells and organ needed.

1.7. Fainting or sudden changes in the level of consciousness
This is an result due to  large volume of blood loss and considered to be life threatening.

1.8. Etc.
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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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