Monday, 2 December 2013

Upper head hemorrhaging: Intracranial hemorrhage - The Types and 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.
Intracranial hemorrhage
 Intracranial hemorrhage is defined as condition of bleeding within the skull.
D.1.1. Types of Intracranial hemorrhage
In the study to evaluate the sensitivity and specificity of head ultrasound (HUS) in the detection of intracranial hemorrhage in premature neonates compared with brain MRI using susceptibility-weighted imaging (SWI), showed that Ultrasound (US) and MRI scans of the brain using SWI in premature neonates were retrospectively evaluated for grade I-III germinal matrix hemorrhage (GMH), periventricular hemorrhagic infarction (PVHI), intra-axial hemorrhage other than PVHI, extra-axial hemorrhage in each cerebral hemisphere and cerebellar hemorrhage in each cerebellar hemisphere(1).
1. Intra-axial hemorrhage (cerebral hemorrhage)
Intra-axial hemorrhage is defined as a condition of  bleeding in the brain itself, including bleeding of the brain tissues and ventricles,

2. Extra-axial hemorrhage
Extra-axial hemorrhage is defined as a condition of skull bleeding outside of the brain

D.1.2. Causes and Rick factors
1. Causes 
a. Malignant melanoma
There is a report of a41-year-old female presented with repeated pontine hemorrhage. Histological examination showed malignant melanoma cells. No cutaneous lesion was found and positron emission tomography found no abnormalities. Our presumptive diagnosis was primary intra-axial brainstem malignant melanoma. The possibility of malignant melanoma should be considered in patients with intra-axial brainstem lesion associated with repeated hemorrhages(2).

b.  Head trauma
Patients receiving warfarin or clopidogrel are considered at increased risk for traumatic intracranial hemorrhage after blunt head trauma. In a study of a total of 1,064 patients were enrolled (768 warfarin patients [72.2%] and 296 clopidogrel patients [27.8%]). There were 364 patients (34.2%) from Level I or II trauma centers and 700 patients (65.8%) from community hospitals. One thousand patients received a cranial CT scan in the ED. Both warfarin and clopidogrel groups had similar demographic and clinical characteristics, although concomitant aspirin use was more prevalent among patients receiving clopidogrel. The prevalence of immediate traumatic intracranial hemorrhage was higher in patients receiving clopidogrel (33/276, 12.0%; 95% confidence interval [CI] 8.4% to 16.4%) than patients receiving warfarin (37/724, 5.1%; 95% CI 3.6% to 7.0%), relative risk 2.31 (95% CI 1.48 to 3.63). Delayed traumatic intracranial hemorrhage was identified in 4 of 687 (0.6%; 95% CI 0.2% to 1.5%) patients receiving warfarin and 0 of 243 (0%; 95% CI 0% to 1.5%) patients receiving clopidogrel(3).


c. High blood pressure
 In a cohort of patients with spontaneous ICH, we obtained ICP values from nursing documentation of hourly vital signs and reviewed charts to rule out spurious ICP recordings, showed that among 243 patients, 57 (24 %) underwent ICP monitoring, of whom 40 (70 %; 95 % CI 57-82 %) had an episode of ICP > 20 mmHg. Intracranial hypertension was less likely in older patients (OR per decade 0.6, 95 % CI 0.3-0.9) and after infratentorial hemorrhage (OR 0.1, 95 % CI 0-0.7). Intracranial hypertension was not independently associated with mRS scores (OR 0.8, 95 % CI 0.3-2.3); this remained true for a threshold of >25 mmHg (OR 0.5, 95 % CI 0.2-1.5), number of elevations (OR 0.98 per elevation, 95 % CI 0.96-1.00), or area under the curve (OR 1.00 per mmHg × h, 95 % CI 0.99-1.01)(4).

d. Cerebral Aneurysms
  Cerebral aneurysm is defined as a cerebrovascular disorder causes of the blood vessel to bulge or balloon out of the wall of a blood vessel as a result of the weaken of blood vessels and veins and occurred mostly at the bifurcations and branches of the large arteries located at the Circle of Willis. It can burst and cause bleeding into the brain(5) leading to Intracranial hemorrhage(5). 

e. Brain Arteriovenous malformations
 Brain Arteriovenous malformations is defined as a condition of abnormal connection between veins and arteries, with a high rate of bleeding into the brain usually congenital.

f. Cerebral Amyloid angiopathy
Cerebral Amyloid angiopathy is defined as a condition of  amyloid build up on the walls of  the blood vessel walls in the brain. Cerebral amyloid angiopathy (CAA) is one of the main causes of intracerebral hemorrhage (ICH), a subtypes of  Intracranial hemorrhage in the elderly, according to the study by the Institut de Recerca, Universitat Autònoma de Barcelona(6).

g. Blood or bleeding disorders.
In the study to analyze the association of the initial platelet count with mortality and progression of intracranial hemorrhage (ICH) in blunt traumatic brain injured (TBI) patients, showed that Of 626 TBI patients, 310 (49.5%) had a minimum of two brain computed tomography scans and were able to have ICH progression evaluated. Patients with platelets <175,000/mm3 had a significantly increased risk for ICH progression (OR [95% CI]: 2.09 [1.07-4.37]; adjusted p = 0.043). ICH progression was associated with increased need for craniotomy (OR [95% CI]: 3.27 [1.28-8.33]; adjusted p = 0.013) and mortality (OR [95% CI]: 3.41 [1.11-10.53]; adjusted p = 0.033). A platelet count <100,000/m3 was an independent predictor for mortality (OR [95% CI]: 9.5 [1.3-71.4]; adjusted p = 0.029)(7).

h. Neurosarcoidosis
Neurosarcoidosis, a complication of sarcoidosis in which inflammation occurs in the nervous system are related intracranial haemorrhage, according to the study by the incorporating the National Children's Hospital, Trinity College(8).

g. Liver disease 
Intracranial hemorrhages and late hemorrhagic disease associated cholestatic liver disease, according to the study of 11 infants with cholestatic liver disease with different etiologies exhibiting intracranial hemorrhage (ICH) to researchers at the  Erciyes University, Erciyesevler Mahallesi(9).

h. Brain tumors
There is a report of  three cases of metastatic brain tumors which began with the symptoms of vascular accident and were demonstrated as high density area by CT scan. Two of them are metastasis of lung cancer and another, hepatoma. Characteristic CT findings are as follow: 1) atypical location 2) non-homogeneous high density area extending from the margin of the tumor (sometimes ring-like appearance) 3) surrounding massive edema 4) positive contrast enhancement 5) multiple lesions(10).

i. Stroke and oral anticoagulants
Use of intravenous tissue-type plasminogen activator (IV tPA) for acute ischemic stroke is restricted to patients with an international normalized ratio (INR) less than 1.7. However, a recent study showed increased risk of symptomatic intracranial hemorrhage after IV tPA use in patients with oral anticoagulants (OAC) even with an INR less than 1.7(11).

j. Etc.
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Sources
(1) http://www.ncbi.nlm.nih.gov/pubmed/22633043
(2) http://www.ncbi.nlm.nih.gov/pubmed/19029781
(3) http://www.ncbi.nlm.nih.gov/pubmed/22626015
(4) http://www.ncbi.nlm.nih.gov/pubmed/22833445
(5) http://diseases-researches.blogspot.ca/p/cerebral-aneurysm.html
(6) http://www.ncbi.nlm.nih.gov/pubmed/22261638
(7) http://www.ncbi.nlm.nih.gov/pubmed/20386283
(8) http://www.ncbi.nlm.nih.gov/pubmed/22681045
(9) http://www.ncbi.nlm.nih.gov/pubmed/22327309
(10) http://www.ncbi.nlm.nih.gov/pubmed/7279131
(11) http://www.ncbi.nlm.nih.gov/pubmed/21980194

Hemorrhaging: Hematuria - The 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.
Hematuria
Hematuria is defined as a medical condition with the presence of blood in the urine.
Treatments(14)
Treatments are depending to the diagnosis of the diseases, including
1. Kidney stones
If the diagnosis found that Hematuria is the result of kidney stone, under normal condition, you are asked to drink plenty water to washout the stone and take pain control medicine. In some conditions, extracorporeal shock wave lithotripsy may be necessary to crush the stones to smaller piece to allow them to pass through via the urinary track. Other case, if the stone is found in the ureter, cystoscopy may help to it.
2. Urinary tract infection:
Urinary track infection is the result of invasion of bacteria, antibiotics will be taken over a certain period depending to types of bacteria.

3. Benign prostate enlargement
In case of hematuria is caused by benign prostate enlargement then alpha blockers and 5α-reductase inhibitors may be taken.

4. Medications: If a medication is the causes of hematuria, then the medication may be replaced with other with the same effectiveness but with no side effect of urinary bleeding, if one can be found. If not, you doctor may weight the benefits and risk of the medicine.

5. Urinary tract blockage: if the disease is caused by a blockage, the surgery may be become necessary generally to correct or remove the block.

6. Etc.
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(14) http://www.aafp.org/afp/2005/0315/p1153.html

Hemorrhaging: Hematuria - 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.
Hematuria
Hematuria is defined as a medical condition with the presence of blood in the urine.
Diagnosis(13)
In the review of 1502 study participants, routine urinalysis was performed in 73.2% and 164 (14.9%) subjects had documented hematuria (>3 red blood cells / high-power field) before inclusion, found that  42.1% had no further evaluation. Additional testing included 
1. Repeat urinalysis (36%),
The aim of urtnalysis, including  physical, chemical, and microscopic examinations, is to diagnose of urologic conditions such as calculi, urinary tract infection (UTI), and malignancy(14).

2. Urine culture (15.2%)
The mid stream urinary test to check for bacteria and germs in the urine. the aim is to test for urinary track infection.

3. Cytology (10.4%)
The aim of the test is to detect the irregular cells growth in the urinary track.

4. Imaging (22.6% overall
The aim of the test is to  evaluate the urinary tract including the kidneys, ureters, bladder, prostate, or urethra.
4.1.15.9% Computed tomography
The best choice to evaluate the kidneys and ureters.
4.2. 4.3% intravenous pyelography
Similar in analyzing the kidneys and ureters
4.3.  2.4% magnetic resonance imaging, and
Similar in analyzing the kidneys and ureters 
4.4. Cystoscopy (12.8%).
The best choice to examine the bladder with the use of a thin, flexible cystoscope which is insert in to the bladder via the urethra 
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(13) http://www.ncbi.nlm.nih.gov/pubmed/20564400

Hemorrhaging: Hematuria - Symptoms and signs

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.
Hematuria
Hematuria is defined as a medical condition with the presence of blood in the urine.
Symptoms and signs
1. There is a report of healthy 60-year-old man presented with urinary urgency and microhematuria, The workup revealed no urothelial lesions, but did suggest a calcified intraperitoneal mass causing extrinsic compression of the bladder. Laparoscopic exploration revealed a glistening, spherical mass attached by a stalk to the sigmoid colon. Removal and histologic examination of the mass revealed calcified fat necrosis, most likely due to the spontaneous torsion and calcification of an appendix epiploicae(10).

2. Blood clots
 Massive hematuria of renal origin was diagnosed in 4 dogs. In all dogs, blood and blood clots were clearly visible in the urine, according to study by Stone EA and researcher team(11).

3. Burning sensation 
It may be result of inflammation or infection of the urinary track.

4. Pain when urinating (dysuria)
Telephone and clinic interviews identified 21 patients (36%) with symptoms of the dysuria and hematuria syndrome. The most common symptoms were hematuria (71%) and bladder or suprapubic pain (76%). Of the patients 18 (86%) ranked the severity of symptoms as mild to moderate and 3 (14%) ranked them as severe, according to the study by the University of Washington(12).

5. Fever  
As a result of infection or inflammation

6. Weight loss and flank pain
There is a report of 37-year-old man with a history of bladder augmentation presented with gross hematuria, weight loss and flank pain, according to thye study of Department of Clinical Urology, University of Southern California Keck School of Medicine

7.  Etc.
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Sources
(10) http://www.ncbi.nlm.nih.gov/pubmed/11880093
(11) http://www.ncbi.nlm.nih.gov/pubmed/6629996
(12) http://www.ncbi.nlm.nih.gov/pubmed/8326629  

Hemorrhaging: Hematuria - the Causes and 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.
Hematuria
Hematuria is defined as a medical condition with the presence of blood in the urine.

C.1 Causes and Risk factors
C.1. Causes
1. According to to the study at the University of Texas Southwestern Medical Center at Dallas,  bladder cancer based on > or = 10 years of smoking or environmental exposure with microscopic hematuria are rarely evaluated thoroughly and only 12.8% were referred for urologic evaluation. Further studies are needed to evaluate both the utilization and effectiveness of guidelines for hematuria(1).

2. Kidney cancer
Tumor compresses onto capillary ot blood vessel can cause blood in the urine.

3. Inflammation 
In the study of 82 of 1209 patients (6.8%), follow-up evaluation was available for 43 of 85 (50.6%) findings by histologic diagnosis (n = 9), imaging evaluation (n = 31), or clinical information (n = 3). There were 11 (0.9%) examinations with acute findings, of which acute inflammation of the gastrointestinal tract and pancreaticobiliary system were the most common. Seventy-two (5.9%) examinations revealed 74 nonacute but important findings(2).

4. Sickle cell disease
There is a report of a case of recurrent gross hematuria, sickle cell trait and von Willebrand's disease is reported. The gross hematuria abated promptly after the institution of cryoprecipitate therapy(3).

5. Oral anticoagulation (OA)
Oral anticoagulation (OA) is a common treatment with a known risk of fatal or major bleeding, but also minor bleeding symptoms and menorrhagia can cause substantial discomfort and necessitate medical or surgical interventions(4).

6. Vigorous exercise
There is a report of during a 6-month Amphibious Task Force deployment to the Mediterranean Sea, five sailors and Marines were admitted to the ship's ward with severe upper extremity pain, elevated serum muscle enzymes, and a urinalysis dip positive for blood in the absence of microscopic hematuria-a finding highly suggestive of myoglobinuria(5).

7. Sexual activity
In the study to assess the relationship between sexual behaviour, urinary symptoms, urinalysis and bacteriuria in men attending STD clinics of 704 patients had had sexual intercourse (SI) within 14 days of testing, 424 had urinary symptoms and 122 had pyuria. All 13 patients with positive culture had SI < 14 days before testing, urinary symptoms and pyuria. No association was found between sexual orientation, type of SI, number of sexual partners, condom usage and bacteriuria(6).

8. Hemorrhagic cystitis 
In the study to evaluate the association between the prevalence of viral infections and hemorrhagic cystitis in pretransplant and posttransplant recipients and donors, showed that detection of single and multiple infections of BK virus, adenovirus, and cytomegalovirus in blood and/or urine samples of hematopoietic stem cell transplant recipients, in combination with 1 or more inducing factors of hemorrhagic cystitis were enforced on the important role these risk factors play in the cause of hemorrhagic cystitis(7).

9. Etc.

C.2. Risk factors 
1. Family history 
PKD1 gene abnormality is responsible for 85% of cases of ADPKD, patients with PKD2 mutations typically present later and progress more slowly. Patients with ADPKD can present with a positive family history, hypertension, flank pain, haematuria, renal insufficiency or proteinuria(8). 

2. Other risk factors
In the study to determine the prevalence of urological pathology in a retrospective and prospective study of patients with microscopic haematuria attending a haematuria clinic, between January 1998 and May 2001, 781 patients attended the haematuria clinic; of these, 368 (47%; median age 60 years, range 18-90) had a history of microscopic haematuria, as detected by urine dipstick testing, showed that Urine cytology showed no malignant cells in any patient with a history of microscopic haematuria. In 143 patients (39%), urine cytology showed no red blood cells and all other investigations were normal. Of the remaining 225 patients, IVU showed a tumour in one (bladder), renal stones in 15 and an enlarged prostate in two. Renal ultrasonography detected no additional pathology. Urine analysis showed one urinary tract infection. Flexible cystoscopy detected five patients with a bladder tumour (all G1pTa), two urethral strictures, five bladder stones and enlarged prostates, six enlarged prostates only, and nine red patches in the bladder, showing one patient with carcinoma in situ. No PSA levels were suggestive of prostate cancer(9).


3. Etc.
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Sources
(1) http://www.ncbi.nlm.nih.gov/pubmed/20564400
(2) http://www.ncbi.nlm.nih.gov/pubmed/22915402
(3) http://www.ncbi.nlm.nih.gov/pubmed/313457 
(4) http://www.ncbi.nlm.nih.gov/pubmed/17260163
(5) http://www.ncbi.nlm.nih.gov/pubmed/7816216
(6) http://www.ncbi.nlm.nih.gov/pubmed/8976831
(7) http://www.ncbi.nlm.nih.gov/pubmed/22142049
(8) http://www.ncbi.nlm.nih.gov/pubmed/22497104
(9) http://www.ncbi.nlm.nih.gov/pubmed/12175388

 

Hemorrhaging: Hematochezia (rectal bleeding) -Treatments and 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.
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.
Treatments and managements
5.1. Severe hematochezia
In the study to  evaluate (a) the diagnosis and treatment of 80 consecutive patients with severe, ongoing hematochezia from unknown source and (b) the effectiveness and safety of urgent colonoscopy after oral purge, researcher wrote that because of ongoing severe hematochezia in the intensive care unit, urgent diagnosis and treatment was recommended by the attending physicians and surgeons. Emergency panendoscopy was performed before purge. Urgent colonoscopy was performed in the intensive care unit after patients received oral purge and their gut was cleared of blood, clots, and stool. The final diagnosis in these patients was 74% colonic lesions (30% angiomata, 17% diverticulosis, 11% polyps or cancer, 9% focal ulcers, 7% other), 11% upper gastrointestinal lesions, and 9% presumed small bowel lesions. No lesion site was identified in 6%. Clinically significant fluid retention (medically controlled) occurred in 4% of patients after purge. Sixty-four percent of patients had intervention for control of bleeding: 39% had therapeutic endoscopy, 24% surgery, and 1% therapeutic angiography. For 22 patients who also had emergency visceral angiography, the diagnostic yield was 14% and the complication rate was 9%. and suggested that (a) Oral purge was effective and safe for cleansing the colon of stool, clots, and blood. Sulfate purge appeared to be safer than saline purge. (b) Before urgent colonoscopy and purge, emergency panendoscopy was indicated to exclude an upper gastrointestinal bleeding source. (c) Urgent colonoscopy after purge was effective, safe, and often diagnostic. (d) Compared with urgent colonoscopy, urgent visceral angiography was often nondiagnostic. However, the examinations may be complementary. (e) Hemostasis via colonoscopy has a definitive role in the treatment of some focal colonic lesions such as bleeding angiomata(15).

5.2. In Stable patients 
In the study of to examine 58 patients, presenting with clinical signs of lower GI hemorrhage,  through a 24-month period. Preliminary endoscopy was either negative or unfeasible. Images were obtained with a four-detector row CT with an arterial (4 x 1 mm collimation, 0.8 mm increment, 1.25 mm slice width, 120 kV, 165 mAs) and portal venous series (4 x 2,5 mm collimation, 2 mm increment, 3 mm slice width, 120 kV, 165 mAs). Time interval between endoscopy and CT varied between 30 minutes and 3 hours. The results of the multi-phase Multi-Slice-Computertomography (MSCT) were correlated with clinical course and surgical or endoscopical treatment(16).
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Sources
(15) http://www.ncbi.nlm.nih.gov/pubmed/3263294
(16) http://www.ncbi.nlm.nih.gov/pubmed/16333787

Hemorrhaging: Hematochezia (rectal bleeding) - 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.
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.
Diagnosis
4.1. Colonoscopy and arteriography
In the study of Diagnosis and treatment of hematochezia: guideline for clinical practice, DR. Wandono H. at the Department of Internal Medicine, Hajj Hospital Surabaya wrote that there are difficulties in clinical practice to find the cause and making the diagnosis and therapy for hematochezia. Fortunately, the progress and development in medical technology, especially colonoscopy and arteriography, has assisted in clinical practice(12).


4.2. Blood test
The aim of blood test is to determine the hemoglobin concentration, coagulation and and tests of liver and renal function are useful in checking for factors that may exacerbate bleeding.
4.3. In stable patients
a. In younger patients
If the physical examination or anoscopy reveals a bleeding hemorrhoid or other cause of local anal pathology, no other test is necessary as the possibility of colon cancer is fewer than 1% in those younger than age 30 years.
b. In older patients
80% of colorectal malignancies are found in patients older than the age of 50 years. Even if a local lesion such as a hemorrhoid is discovered. Twenty-seven percent of patients with carcinoma of the rectum and 10% of those with carcinoma of the sigmoid have been noted to have coincidental hemorrhoids. Most patients older than the age of 40 years with rectal bleeding are candidates for colonoscopy.
4.2, 4.3,(13)
4.5. Computed tomography (CT) angiography
CT angiography is an accurate, cost-effective tool in the diagnosis of acute GI bleeding and can show the precise location of bleeding, thereby directing further management, according to the study by  Shanghai Jiao Tong University School of Medicine(14).
4.6. Etc.
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