Hemorrhaging: Upper gastrointestinal bleeding - 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.
Upper gastrointestinal bleeding
Upper gastrointestinal bleeding (UGIB) is defined as hemorrhaging derived from a source proximal to the ligament of Treitz. It is life threatening and considered as medical emergency, which is followed by high mortality rate, ranging from 6 to 15% in spite of modern diagnostic methods and treatment.

J.1. Causes and risk factors
1. Causes
1.1. Esophageal causes of Upper gastrointestinal bleeding
Espophagus or gullet, an organ in vertebrates, is the tube that lead foods from the pharynx to the stomach.
a. Esophageal varices
In the study to investigate the effects of splenectomy and ligature of the left gastric vein on risk factors for bleeding of esophagogastric varices in patients with schistosomiasis mansoni, hepatosplenic form, with a history of upper gastrointestinal bleeding, showed that the variceal pressure has fallen from 22.3+/-2.6 mmHg before surgery to 16.0+/-3.0 mmHg in the immediate postoperative period (p<0.001), reaching 13.3+/- 2.6 mmHg in the sixth month of follow-up. A significant reduction of the frequency of the parameters associated with a greater risk of hemorrhage was observed between the preoperative period and six-month follow-up, when the proportion of large esophageal varices (p<0.05), varices extending to the upper esophagus (p<0.05), bluish varices (p<0.01), varices with red signs (p<0.01) and gastropathy (p<0.05) decreased(1)

b. Esophagitis 
there is a report of a case of recurrent, severe upper gastrointestinal bleeding due to hemorrhagic candidal esophagitis in a man with renal failure is described. Dysphagia, odynophagia, and retrosternal chest discomfort were all absent. Oral thrush was present only at the outset. Standard therapy for massive bleeding with blood products alone was not successful. Intravenous amphotericin eventually resulted in resolution, according to the study by University of Manitoba, Canada(2).

c. Esophageal cancer 
Esophageal cancer is not very uncommon and caused by malignant of the esophagus due to abnormal cell growth as a result of the DNA alternation of the cells that line the upper part of the esophagus or glandular cells that are present at the lower part of the esophagus that connected with the stomach.
The esophageal cancer tend to spread if it left untreated and starts from the lining of esophagus, then later penetrate in the the wall of the esophagus and spread to the lumph node around the bottom of the esophagus, stomach and the chest, then to the distant parts of the body. for more information, please visit
http://medicaladvisorjournals.blogspot.ca/2011/06/cancers-from-b-to-t-most-common-types_07.html

d. Esophageal ulcers 
there is a report of five cases in the upper GI tract due to insufflating large amounts of air through the endoscopes. All 5 patients needed an emergency upper endoscopy for acute presumed upper GI bleeding. In two cases both esophageal variceal bleeding and ulcer bleeding were detected; the fifth case presented with a bleeding due to gastric cancer(3).

e. Other causes
Other causes of UGI bleeding include Dieulafoy's lesion, Mallory-Weiss syndrome, and portal hypertensive enteropathy. The most common non-variceal endoscopic findings reported in patients with lower gastrointestinal bleeding are portal hypertensive colopathy and hemorrhoids(4). 

1.2. Gastric causes of Upper gastrointestinal bleedinga
a. Gastric ulcer 
There is a report iIn 16 patients (mean age, 59.4 years) with acute bleeding ulcers (13 gastric ulcers, 2 duodenal ulcers, 1 malignant ulcer), a metallic clip was placed via gastroscopy and this had been preceded by routine endoscopic treatment, according to the study of Chonbuk National University Medical School(5).

b. Gastric cancer 
Bleeding from the upper gastrointestinal system may be caused by gastrointestinal stromal tumors of the stomach, which are mainly characterized by occult bleeding, while profuse bleeding rarely occurs accompanied by hemorrhagic shock. Gastrointestinal stromal tumors of stomach are the most common mesenchimal tumors of the gastrointestinal tract(1). For more information of Stomach Cancer/Gastric Cancer, please visit http://medicaladvisorjournals.blogspot.ca/2011/06/cancers-from-b-to-t-most-common-types_30.html

c. Gastritis 
In a material of 4560 panendoscopic investigations carried out in an endoscopy laboratory haemorrhages from the upper gastrointestinal tract were found in 201 cases. In 49 cases the cause of blood loss was acute haemorrhagic gastritis. Among them males accounted for 41% (mean age 35.6 years) and females for 59% (mean age 41.8 years)(6).

d. Gastric varices 
Although most portal hypertensive bleeds result from the ruptured distal esophageal varices, bleeding from other sources such gastric varices, portal hypertensive gastropathy, and ectopic varices can lead to clinically significant bleeding. Variceal bleeding typically presents as massive gastrointestinal (GI) bleeding with hematemesis, melena or hematochezia(7).

e. Gastric antral vascular ectasia 
Gastric antral vascular ectasia (GAVE) syndrome, also known as watermelon stomach is a significant cause of acute or chronic gastrointestinal blood loss in the elderly. is characterized endoscopically by "watermelon stripes." Without cirrhosis, patients are 71% female, average age 73, presenting with occult blood loss leading to transfusion-dependent chronic iron-deficiency anemia, severe acute upper gastrointestinal bleeding, and nondescript abdominal pain(8).

f. Dieulafoy's lesions
Dieulafoy's lesions are considered uncommon causes of gastrointestinal bleeding and occur from pinpoint non-ulcerated arterial lesions(9).

g. Etc.

1.3. Duodenal causes of Upper gastrointestinal bleeding
The duodenum represents second place in frequency for the presence of diverticula in the digestive tract after the colon. Duodenal diverticulum as a cause of hemorrhage of the upper gastrointestinal (GI) tract has been described as an infrequent complication, although it must be considered in patients with digestive hemorrhage without evident cause at the esophagogastric level(10).

1.4. Etc.

2. Risk factors
a. Medication
Medication such as aspirin, NSAIDs, warfarin, corticosteroids and SSRIs are associated with increase risk of upper gastrointestinal bleeding. In the study assess the impact of increased use of low-dose aspirin, other non-steroidal anti-inflammatory drugs (NSAIDs), warfarin, corticosteroids and selective serotonin re-uptake inhibitors (SSRIs) on the site and outcome of non-variceal gastrointestinal (GI) bleeds, researchers at the Lund University, Lund, Sweden, found that aspirin, warfarin and SSRI users tended to suffer more severe GI bleeds than non-users of these drugs. When comparing non-ulcer GI bleeds with PUBs, aspirin (OR 0.56, 95% CI 0.38-0.82) was more strongly associated with PUBs, whereas SSRIs (OR 3.71, 95% CI 1.39-12.9) and corticosteroids (OR 2.8, 95% CI 1.28-6.82) were more associated with non-ulcer GI bleeds after adjusting for age, gender and co-morbidity(11).

b. Acid reflux disease
Gastrointestinal (GI) complaints are common among athletes with rates in the range of 30% to 70%. Both the intensity of sport and the type of sporting activity have been shown to be contributing factors in the development of GI symptoms. Three important factors have been postulated as contributing to the pathophysiology of GI complaints in athletes: mechanical forces, altered GI blood flow, and neuroendocrine changes. As a result of those factors, gastroesophageal reflux disease (GERD), nausea, vomiting, gastritis, peptic ulcers, GI bleeding, or exercise-related transient abdominal pain (ETAP) may develop(12). For more information of gastroesophageal reflux disease (GERD), please visit
In the General Health Section at http://kylejnorton.blogspot.ca/p/general-health.html

c. Age
Upper GI bleeding was significantly correlated with age younger than 50 (P = .01) and male gender (P = .01; odds ratio, 3.13)(13).

d. Coagulopathy
Coagulopathy was prevalent in 16% of patients after nonvariceal upper gastrointestinal bleeding (NVUGIB). and independently associated with more than a fivefold increase in the odds of in-hospital mortality. Wide variation in plasma use exists indicates clinical uncertainty regarding optimal practice(14).

e. Etc.
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Sources
(1) http://www.ncbi.nlm.nih.gov/pubmed/22569978
(2) http://www.ncbi.nlm.nih.gov/pubmed/8202782
(3) http://www.ncbi.nlm.nih.gov/pubmed/22649332
(4) http://www.ncbi.nlm.nih.gov/pubmed/22661272
(5) http://www.ncbi.nlm.nih.gov/pubmed/21852908
(6) http://www.ncbi.nlm.nih.gov/pubmed/2623868
(7) http://www.ncbi.nlm.nih.gov/pubmed/22514572
(8) http://www.ncbi.nlm.nih.gov/pubmed/20740102
(9) http://www.ncbi.nlm.nih.gov/pubmed/20514835
(10) http://www.ncbi.nlm.nih.gov/pubmed/18492423
(11) http://www.ncbi.nlm.nih.gov/pubmed/20695720
(12) http://www.ncbi.nlm.nih.gov/pubmed/22897615
(13) http://www.ncbi.nlm.nih.gov/pubmed/9928705
(14) http://www.ncbi.nlm.nih.gov/pubmed/22897615

Hemorrhaging: Ovarian hemorrhage

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.
Ovarian hemorrhage
Approximately 4% of women are admitted to hospitals because of ovarian cyst rupture, hemorrhage, or torsion.
In the a study of Ovarian hemorrhage after transvaginal ultrasonographically guided oocyte aspiration: a potentially catastrophic and not so rare complication among lean patients with polycystic ovary syndrome, researchers at the Department of Obstetrics and Gynecology, Shaare Zedek Medical Center found that although acute hemorrhage is a rare event after TVOA, lean patients with PCOS specifically are at much higher risk for this complication(1).
Others report of a case of an 18-year-old female with EBV-associated ITP, who developed a severe intra-abdominal bleed secondary to a hemorrhagic ovarian cyst. Females in this age group are in their early childbearing years and present a unique set of possible hemorrhagic complications not seen in younger patients(2).

Please check the following articles in the Women health section  for more information of ovarian bleeding  at http://kylejnorton.blogspot.ca/p/women-health.html
1. Ovarian Cysts In Conventional Medicine Perspective
2. Ovarian Cysts In Traditional Chinese Medicine Perspective
3. Endometriomas - Chocolate Cysts - In Conventional Medicine Perspective
4. Endometriomas - Chocolate Cysts - In Traditional Chinese Medicine  

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Hemorrhaging: Breakthrough 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.

H. Breakthrough bleeding 
Breakthrough bleeding is defined as a condition of an abnormal flow of blood from the uterus that occurs between menstrual periods especially due to irregular sloughing of the endometrium in women on contraceptive hormones(1).
H.3. Treatments and Managements
1. Ongoing study
In the study of to evaluate doxycycline, a common antibiotic used to treat infections and acne, as a possible treatment in preventing or stopping unexpected menstrual bleeding in women, tf the study shows the drug is successful in stopping "breakthrough bleeding," more women may turn to new continuous contraception options – options that allow women to effectively stop menstrual bleeding, said study investigator Bliss Kaneshiro, M.D.,instructor in obstetrics and gynecology, OHSU School of Medicine(7).
Treatment and Management depening to the unlined causes, include
2.  Excessive thick uterine lining (edometrium) 
First, certain tests must be taken to rule out the cause of endometrial cancer(8). The excessive thicken endometrium may be as a result of estrogenic stimulation, wrong use of oral contraceptives, medication such tamoxifen, obese cause of excess estrogen due to fat, etc.

3. Oral contraceptives(9)
If the breakthrough breeding is a result of the use of oral contraceptive, some researchers suggested
a. Missed pills, late pills, irregular taking. Probably the commonest cause of breakthrough bleeding
b. Breakthrough bleeding is more common in the first six months and will often settle.
c. Infectous diseases, especially chlamydia which not infrequently presents with a history of abnormal bleeding.
d. Drugs, especially enzyme inducers which increase the metabolic transformation
of the hormones as they pass through the liver thereby decreasing contraceptive blood levels.
e. Gastrointestinal upsets are well recognised as a cause of breakthrough bleeding due to impairment of absorption.
g. Some foods are enzyme inducers
h. The formulation may need changing but think of this last rather than first. Breakthrough bleeding is more common with the low oestrogen pills but may settle if given time. A triphasic formulation will often give good cycle control. Try changing the type of progestogen.

4. Amenorrhea
If breakthrough is a result of medication-induced Amenorrhea, then taking off medication,  normal menstruation resumes in the cycle after they are discontinued.

5.  Hormonal fluctuations
In this practice guideline, the management guidelines are limited to the treatment of bleeding from the endometrium. In most cases bleeding caused by hormonal fluctuations is self-limiting. However, symptomatic treatment with progestogens or sub-50 oral contraceptives is possible. NSAIDs taken during the first three days of menstruation are the second-choice treatment in women with excessive bleeding. Tranexamic acid or a levonorgestrel-releasing IUD are other possibilities. (10) 

5. Progestin treatment
Clinicians routinely prescribe progestins along with estrogens during menopausal hormone therapy (HT) to block estrogen-dependent endometrial proliferation. Breakthrough bleeding (BTB) can negate the utility of this treatment. Because progestin antagonists also inhibit estrogen-dependent endometrial proliferation in women and macaques, we used a menopausal macaque model to determine whether a potent progestin antagonist (ZK 230 211, Schering AG; ZK) combined with estrogen would provide a novel mode of HT(11)
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Sources
(1) http://www.merriam-webster.com/medical/breakthrough%20bleeding
(7) http://www.ohsu.edu/xd/about/news_events/news/2007-news-archive/08-27-drug-may-hold-key-to-pre.cfm
(8) http://medicaladvisorjournals.blogspot.ca/2011/06/cancers-from-b-to-t-most-common-types_05.html.
(9) http://www.rnzcgp.org.nz/assets/documents/Publications/Archive-NZFP/Dec-2002-NZFP-Vol-29-No-6/Sparrow-December-02.pdf
(10) http://www.ncbi.nlm.nih.gov/pubmed/12467159
(11) http://www.ncbi.nlm.nih.gov/pubmed/16936297 
 

Hemorrhaging: Breakthrough bleeding - The Preventions

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.

H. Breakthrough bleeding 
Breakthrough bleeding is defined as a condition of an abnormal flow of blood from the uterus that occurs between menstrual periods especially due to irregular sloughing of the endometrium in women on contraceptive hormones(1).
Prevention 
1. Lose weight
Accumulation of fat in obese women can cause the increased risk of breakthrough bleeding due to ongoing production of estrogen.

2. Smoking
Smoking can interfere with menstrual control of oral contraceptive that can lead to breakthrough bleeding.

3. Reduce intake of enzyme inducers

4.  Mifepristone
in the study to determine if mifepristone would decrease BTB in new starters of DMPA. Twenty regularly cycling women who were new starters of DMPA were randomized to receive 50 mg of mifepristone or placebo every 2 weeks for 24 weeks, researchers at the University of Southern California Keck School of Medicine, showed that percent days of BTB and number of cycles with bleeding intervals > or =8 and > or =14 days were evaluated using daily bleeding diaries. Ovulation was determined by measuring thrice-weekly urinary metabolites of estrogen and progesterone. Endometrial concentrations of ER and PR were determined by immunohistochemistry. Mifepristone significantly decreased the percent days of BTB and the number of cycles with prolonged bleeding intervals when compared to placebo. No subject ovulated in either group. ER immunostaining increased and PR immunostaining decreased after mifepristone treatment. In conclusion, a 50 mg dose of mifepristone taken every 2 weeks decreases the incidence of BTB in new starters of DMPA. This effect may be due to modulation of endometrial estrogen and progesterone receptors(6).

5. Etc. 
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Sources
(1) http://www.merriam-webster.com/medical/breakthrough%20bleeding
(6) http://www.ncbi.nlm.nih.gov/pubmed/14668006

Hemorrhaging: Breakthrough bleeding - 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.

H. Breakthrough bleeding 
Breakthrough bleeding is defined as a condition of an abnormal flow of blood from the uterus that occurs between menstrual periods especially due to irregular sloughing of the endometrium in women on contraceptive hormones(1).

H.1. Causes and Risk factors
1. Excessive thick uterine lining (edometrium) 
During the last stage of the menstrual cycle, normally a layer of endometriosis lining on the inside of the uterus is expelled, known as menstruation blood. In some women, excessive thick of uterine lining (edometrium) may cause breakthrough bleeding.

2. Hormonal fluctuations
Fluctuating hormones around ovulation may experience breakthrough bleeding.

3. Taking oral contraceptives
In the study of  dilated thin-walled blood and lymphatic vessels in human endometrium: a potential role for VEGF-D in progestin-induced break-through bleeding, researchers at the Department of Obstetrics and Gynaecology and Monash Institute for Medical Research, Monash University, wrote that using a NOD/scid mouse model with xenografted human endometrium we were able to show that progestin treatment causes decidualisation, VEGF-D production and endometrial vessel dilation. Our results lead to a novel hypothesis to explain BTB, with stromal cell decidualisation rather than progestin treatment per se being the proposed causative event, and VEGF-D being the proposed effector agent(2).

4.  Amenorrhea
In the study of The induction of amenorrhoea by Hipkin LJ. indicated that a survey has shown that many women favour eliminating menstruation and it has been suggested that therapeutic induction of amenorrhoea might be an advantage in female personnel mobilised for war, but it poses some side effects including bleeding and spotting, 2 kg weight gain, breast tenderness, depression, and headaches(3).

5. Progestin treatment
Clinicians routinely prescribe progestins along with estrogens during menopausal hormone therapy (HT) to block estrogen-dependent endometrial proliferationmay cause breakthrough bleeding.

6. Polyps
In teh study to determine the effectiveness of different treatments for abnormal uterine bleeding in women with known endometrial polyps, showed that  polypectomy and other treatments of women with abnormal uterine bleeding who had benign polyps detected by sonohysterography. Women with endometrial polyps diagnosed by sonohysterography between January 1997 and July 1998 were sent questionnaires on pretreatment and posttreatment uterine bleeding and satisfaction with their treatments(4).

7. Other causes
Stopping or missing estrogens or oral contraceptives, stress, weight gain or loss, diet change, displaced intra uterine device, vagina injury, taking anticoagulant medications, etc.(5)

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Sources
(1) http://www.merriam-webster.com/medical/breakthrough%20bleeding
(2) http://www.ncbi.nlm.nih.gov/pubmed/22383980
(3) http://www.ncbi.nlm.nih.gov/pubmed/1533675 
(4) http://www.ncbi.nlm.nih.gov/pubmed/11084172 
(5) http://www.targetwoman.com/articles/breakthrough-bleeding.html
 

Hemorrhaging: Postpartum hemorrhage - 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.
Postpartum hemorrhage
Postpartum hemorrhage (PPH) is a loss of blood greater than 500 ml, following vaginal delivery, or 1000 ml,  following cesarean section.The mortility rate is of 1000 women per 100,000 live births as a result of Postpartum hemorrhage (PPH). In the evaluation of all  randomly assigned participants,active bleeding was controlled within 20 min with study treatment alone for 440 (90%) women given misoprostol and 468 (96%) given oxytocin (relative risk [RR] 0·94, 95% CI 0·91—0·98; crude difference 5·3%, 95% CI 2·6—8·6). Additional blood loss of 300 mL or greater after treatment occurred for 147 (30%) of women receiving misoprostol and 83 (17%) receiving oxytocin (RR 1·78, 95% CI 1·40—2·26). Shivering (229 [47%] vs 82 [17%]; RR 2·80, 95% CI 2·25—3·49) and fever (217 [44%] vs 27 [6%]; 8·07, 5·52—11·8) were significantly more common with misoprostol than with oxytocin. No women had hysterectomies or died(1).
Treatments
According to the researchers at the Department of Obstetrics and Gynecology, Orbis Medical Centre, in the current treatment of severe PPH, first-line therapy includes transfusion of packed cells and fresh-frozen plasma in addition to uterotonic medical management and surgical interventions. In persistent PPH, tranexamic acid, fibrinogen, and coagulation factors are often administered. Secondary coagulopathy due to PPH or its treatment is often underestimated and therefore remains untreated, potentially causing progression to even more severe PPH. In most cases, medical and transfusion therapy is not based on the actual coagulation state because conventional laboratory test results are usually not available for 45 to 60 minutes. Thromboelastography and rotational thromboelastometry are point-of-care coagulation tests. A good correlation has been shown between thromboelastometric and conventional coagulation tests, and the use of these in massive bleeding in nonobstetric patients is widely practiced and it has been proven to be cost-effective. Fibrinogen seems to play a major role in the course of PPH and can be an early predictor of the severity of PPH. The FIBTEM values (in thromboelastometry, reagent specific for the fibrin polymerization process) decline even more rapidly than fibrinogen levels and can be useful for early guidance of interventions(12).

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Sources
(1) http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2961924-3/abstract
(12) http://www.ncbi.nlm.nih.gov/pubmed/22430921   

Hemorrhaging: Postpartum hemorrhage- Managements and 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.
Postpartum hemorrhage
Postpartum hemorrhage (PPH) is a loss of blood greater than 500 ml, following vaginal delivery, or 1000 ml,  following cesarean section.The mortility rate is of 1000 women per 100,000 live births as a result of Postpartum hemorrhage (PPH). In the evaluation of all  randomly assigned participants,active bleeding was controlled within 20 min with study treatment alone for 440 (90%) women given misoprostol and 468 (96%) given oxytocin (relative risk [RR] 0·94, 95% CI 0·91—0·98; crude difference 5·3%, 95% CI 2·6—8·6). Additional blood loss of 300 mL or greater after treatment occurred for 147 (30%) of women receiving misoprostol and 83 (17%) receiving oxytocin (RR 1·78, 95% CI 1·40—2·26). Shivering (229 [47%] vs 82 [17%]; RR 2·80, 95% CI 2·25—3·49) and fever (217 [44%] vs 27 [6%]; 8·07, 5·52—11·8) were significantly more common with misoprostol than with oxytocin. No women had hysterectomies or died(1).
Prevention and management
According to the article of Active versus expectant management in the third stage of labour (Review) by Prendiville WJ, Elbourne D, McDonald S, routine ’active management’ is superior to ’expectant management’ in terms of blood loss, post partum haemorrhage and other serious complications of the third stage of labour. Active management is, however, associated with an increased risk of unpleasant side effects (eg nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in amaternity hospital. The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries)(10).
 
G.4. Diagnosis and Treatments 
1. Diagnosis
The aim of diagnosis is to determine the underlined causes of the disease, inmost cases , it is caused by 4Ts. Estimation of blood loss by calibrated bags has been shown to be significantly more accurate than visual estimation at vaginal delivery. Careful monitoring of the mother's vital signs, laboratory tests, in particular coagulation testing, and immediate diagnosis of the cause of PPH are important key factors to reduce maternal morbidity and mortality(11).
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Sources
(1) http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2961924-3/abstract
(10) http://apps.who.int/rhl/reviews/CD000007.pdf
(11) http://www.ncbi.nlm.nih.gov/pubmed/21332452