Diseases

The diagnosis of internal bleeding begins with a thorough history taken by the health care professional. This is followed by a physical examination, concentrating on the area of the body where the internal bleeding may have occurred. For example, if there is concern about bleeding in the brain, the physical examination will focus on the neurologic system, or if it is intra-abdominal bleeding, the exam will be directed toward the abdomen. Blood tests may be performed to check for a low red blood cell count, or anemia. However, if the bleeding occurs rapidly, the initial hemoglobin reading or red blood cell count may be normal. The suspicion of internal bleeding will often require an imaging test to look for the bleeding source.

• If there is concern that there is gastrointestinal bleeding, a gastroenterologist may use fiber optic scopes to look into the esophagus and stomach (endoscopy) or into the colon (colonoscopy) to identify the source. If found, the physician may be able to stop the bleeding using electricity to cauterize or burn the blood vessel that is bleeding.
• Computerized tomography (CT) is the most common test to look for bleeding in the brain. It is also able to identify brain swelling and fractures of the skull.
• Ultrasound may be used to look for blood in the abdomen. While it has its place in the management of trauma, ultrasound is especially useful in evaluating obstetric and gynecologic problems such as bleeding from an ovarian cyst or an ectopic or tubal pregnancy.
• Computerized tomography is an effective tool in looking for intra-abdominal and retroperitoneal bleeding. It can evaluate the potential injury site, the severity of organ damage, whether the bleeding is contained within an organ (such as the liver, kidney or spleen) or whether the bleeding has spilled into the peritoneum. It is also a helpful test in assessing pelvic fractures.
• If the source of bleeding is thought to be due to a damaged artery, angiography may be used to evaluate the arterial blood flow.

In some situations in which the patient is critically ill from internal bleeding, the decision may be made to undergo emergency surgery to find and repair the bleeding site. This may occur in trauma victims with abdominal or chest injuries that have unstable vital signs (decreased level of consciousness, low blood pressure, and other signs of shock) and are at risk for bleeding to death if they were to wait for diagnostic tests.

The initial treatment plan of any patient with internal bleeding begins with assessing the patient's stability and making certain the ABCs are well maintained. This includes making certain the patient's:

• Airway is open,
• that the patient is Breathing, and
• there is adequate Circulation, meaning stable pulse rate and blood pressure.

The definitive treatment of internal bleeding depends upon where the bleeding located, the individual situation, and the stability of the patient. The basic goals include identifying and stopping the source of bleeding and repairing any damage that the bleeding may have caused. In patients who take anti-coagulation medications and have significant bleeding, medication reversal of the anti-coagulation may need to occur.

Depending upon where it occurs, if not recognized, internal bleeding may cause organ failure, shock, and death. For example:

• If there is uncontrolled bleeding in the chest or abdomen, the body may lose enough circulating red blood cells to compromise oxygen delivery to cells in the body. Cells shift from aerobic metabolism using oxygen to anaerobic metabolism. This is only a temporary fix and if allowed to continue, the acid-base balance of the body is adversely affected. If enough cells stop working, the body's organs will also begin to fail. This situation is called shock. If the bleeding is not stopped and if fluid resuscitation and perhaps blood transfusion are not provided, the patient may die.
• Internal bleeding in the brain may cause minimal damage or it may lead to stroke-like symptoms, coma, and death. Symptoms depend upon the location of the bleeding, the amount of bleeding, and whether the bleeding causes increased pressure within the skull, further affecting brain function.

The symptoms of internal bleeding depend upon where the bleeding is located, how much bleeding has occurred, and what structures and functions in the body are affected. Blood outside the circulatory system (the heart and blood vessels) is very irritating to tissues, causing inflammation and pain. Examples of some internal bleeding situations are listed below. Intracranial bleeding from trauma or from a leaking aneurysm often causes pain, but may also result in symptoms of altered mental function. Subarachnoid bleeding often causes headache and a stiff neck (meningismus). Neurological examination can range from a near-normal exam to confusion to coma. Symptoms of stroke, including weakness, slurred speech, and loss of vision, may also be associated with intracranial bleeding. The signs and symptoms depend upon where and how much blood there is in the brain. If the bleeding continues, symptoms become progressive and easier to recognize. Bleeding may also occur within the spinal canal and affect spinal cord function. Intra-abdominal bleeding may be hidden and present only with pain, but if there is enough blood loss, the patient may complain of weakness, lightheadedness, shortness of breath, and other symptoms of shock and decreased blood pressure. Once again, the symptoms depend upon where in the abdomen the bleeding occurs.

• If there is bleeding in the stomach, the patient may vomit bright red blood, or if it has been in the stomach for a period of time, the vomit may look like coffee grounds. Blood in the stool may be due to bleeding anywhere in the gastrointestinal tract, from the esophagus and stomach to the colon, rectum and anus. Hemorrhoids are a common cause of blood in the toilet bowel. Black, tarry stools usually signal bleeding from the stomach or duodenum. Black stool may also be due to iron pills, bismuth (PeptoBismol) and some foods. If internal bleeding causes blood to spill into the peritoneum, there can be a significant amount of pain with any movement, and the abdomen can become tense and feel rigid to touch.
• Sometimes intra-abdominal blood will track toward the skin and can be appreciated on physical examination. Cullen's sign is the term used to refer to the appearance of bruising surrounding the umbilicus. Grey-Turner sign is bruising in the flanks.

Blood seen in the urine may be due to internal bleeding at any site within the urinary tract, from the kidney to the bladder. Often bladder infections are associated with blood in the urine, but other causes, inclduing kidney and bladder cancer, need to be considered based upon the particular symptoms, patient's age, and medical history. Males who may have had prostate surgery may have blood in the urine. Men and women who have had radiation therapy may develop inflammation of the bladder wall that can cause a significant amount of bleeding. Some patients with kidney stones may experience blood in their urine. Bleeding may occur deep within muscles after injury, and rarely, compartment syndrome may occur. Muscles are often sheathed in tight linings. Should enough bleeding and swelling cause the pressure within the muscle compartment to be greater than the patient's blood pressure, blood cannot be pumped to the muscle cells and beyond. Symptoms include intense pain, difficulty moving the joints below the injury, and loss of sensation. Most commonly this is seen in the shin and forearm injuries and may or may not be associated with a broken bone. Bleeding may also occur into joints, causing significant pain and loss of range of motion. This most frequently is seen in patients who are on anti-coagulation medications. An injury may or may not be needed to cause the bleeding.

Bleeding most often occurs due to injury, and depending upon the circumstances, the amount of force required to cause bleeding can be quite variable. Some people can experience spontaneous bleeding not necessarily related to any injury or trauma. Blunt trauma Most people understand that falling from a height or being involved in a car accident can inflict great force and trauma upon the body. If blunt force is involved, the outside of the body may not necessarily be damaged, but enough compression may occur to internal organs to cause injury and bleeding.

• Imagine a football player being speared by a helmet to the abdomen. The spleen or liver may be compressed by the force and cause bleeding inside the organ. If the hit is hard enough, the capsule or lining of the organ can be torn, and the bleeding can spill into the peritoneum (the space in the abdominal cavity that contains abdominal organs such as the intestines, liver, and spleen).
• If the injury occurs in the area of the back or flank, where the kidney is located, retroperitoneal bleeding may occur.
• The same mechanism causes bleeding due to crush injuries. For example, when a weight falls on a foot, the weight doesn't give, nor does the ground. The force needs to be absorbed by either the bone or the muscles of the foot. This can cause the bone to break and/or the muscle fibers to tear and bleed.
• Other structures are compressible and may cause internal bleeding. For example, the eye can be compressed in the orbit when it is hit by a fist or a ball. The globe deforms and springs back to its original shape. Rarely, intraorbital hemorrhage (caused by orbital trauma) may occur.

Deceleration trauma Deceleration may cause organs in the body to be shifted inside the body. This may shear blood vessels away from the organ and cause bleeding to occur. This is often the mechanism for intracranial bleeding such as epidural and subdural hematomas and subarachnoid hemorrage or bleeding. Force applied to the head causes an acceleration/deceleration injury to the brain, causing the brain to "bounce around" inside the skull. This can tear some of the small bridging veins on the surface of the brain and cause bleeding. Since the brain is encased in the skull, which is a solid structure, even a small amount of blood can increase pressure inside the skull and decrease brain function. The shaking within the skull may also cause bleeding within the brain tissue itself (intracerebral hemorrhage). Organs within the abdominal cavity are often attached by a pedicle (stalk) to arteries and veins that provide blood supply. In a deceleration injury, the pedicle can shear off, tearing the blood vessels, causing bleeding. Fractures Bleeding may occur with broken bones. Bones contain the bone marrow in which blood production occurs. They have rich blood supplies, and significant amounts of blood can be lost with fractures. The break of a long bone such as the thigh bone (femur) can result in the loss of one unit (350 cc to 500cc) of blood. Flat bones such as the pelvis require much more force to cause a fracture, and many blood vessels that surround the structure can be torn by the trauma and cause massive bleeding. Pregnancy Bleeding in pregnancy is never normal, though not uncommon in the first trimester, and is a sign of a potential miscarriage. In the first few weeks of pregnancy, there is concern that vaginal bleeding is a potential sign of tubal or ectopic pregnancy, in which the placenta and the fetus implant in the Fallopian tube or another location outside of the uterine cavity. As the placenta grows, it erodes through the tube or other involved organs and may cause fatal bleeding unless the ectopic pregnancy is recognized and treated. Bleeding after 20 weeks of pregnancy may be due to placenta previa or placental abruption, and urgent medical care should be accessed. Placenta previa describes the situation in which the placenta attaches to the uterus close to the opening of the cervix and may cause painless vaginal bleeding. Abruption occurs when the placenta partially separates from the uterine wall and causes significant pain with or without bleeding from the vagina. Bleeding after surgery Whenever a surgeon cuts into the body, the potential for immediate and delayed bleeding exists. When the operation is near completion, the surgeon tries to make certain that all bleeding has been controlled. This can be done by identifying and tying off blood vessels with sutures or using staples or clips to maintain hemostasis (hemo=blood + stasis=inactivity, lack of flow). Cautery can be used to burn blood vessels to prevent them from bleeding. A little bleeding can be expected in most situtaions. Sometimes, however, bleeding may occur after the surgery is performed. Blood vessels that have been cut may go into spasm with no evidence of bleeding. They may relax and begin bleeding many hours or days after the completion of a procedure. Similarly, sutures, staples, or clips can dislodge and allow a blood vessel to bleed. Many times the bleeding is self-limited as the body is able to repair itself. On occasion, the patient needs to be returned to the operating room so that the surgeon can explore the area and find the bleeding site. Depending upon the situation, an interventional radiologist may be able to find the bleeding blood vessel and repair it. Spontaneous bleeding Internal bleeding may occur spontaneously, especially in those people who take anticoagulation medications or who have inherited bleeding disorders. Routine bumps that occur in daily life may cause significant bleeding issues. Medication Internal bleeding in the gastrointestinal tract may be caused as a side effect of medications (most often from nonsteroidal anti-inflammatory drugs such as ibuprofen and aspirin) and alcohol. These substances can cause inflammation and bleeding of the esophagus, stomach, and duodenum, the first part of the small intestine as it leaves the stomach. Alcohol abuse Long-term alcohol abuse can also cause liver damage, which may cause bleeding problems through a variety of mechanisms including decreased protein and clotting factor production. Cirrhosis, or scarring of the liver, changes blood flow to the liver and leads to portal hypertension (increased pressure within the blood vessels that supply the liver). Esophageal varices (swollen blood vessels around the esophagus) may develop when the liver's blood supply is altered, and these swollen blood vessels that line the esophagus are prone to bleeding. As well, alcohol can be directly irritating to the lining of the stomach, leading to inflammation that can result in bleeding.

While the general public understands that internal bleeding means bleeding that can't be seen on the outside of the body, medical personnel tend to use terms that describe more precisely the location inside the body where the bleeding is found. The internal bleeding may occur within tissues, organs, or in cavities of the body including the head, spinal canal, chest, and abdomen. Examples of other potential sites of bleeding include the eye and within tissues that line the heart, muscles, and joints. Bleeding outside the body is quite easy to recognize. If the skin is damaged by a laceration, puncture, or abrasion, blood can be witnessed as it streams out of the body. The scalp and face have a very rich blood supply and are notorious for demonstrating massive blood loss. Internal bleeding may be much more difficult to identify. It may not be evident for many hours after it begins, and symptoms may only occur when there is significant blood loss or if a blood clot is large enough to compress an organ and prevent it from functioning properly. Internal bleeding occurs when damage to an artery or vein allows blood to escape the circulatory system and collect inside the body. The amount of bleeding depends upon the amount of damage to an organ, the blood vessels that supply it, and the body's ability to repair breaks in the walls of the blood vessels. The repair mechanisms available include both the blood clotting system and the ability of blood vessels to go into spasm to decrease blood flow to an injured area. People who take blood-thinning or anti-clotting medication are more prone to bleeding than people who do not take these medications. These individuals may experience significant bleeding even with relatively minor injury or illness, and the risk of bleeding needs to be balanced against the benefits of taking the medication. A variety of "blood thinning" medications are now prescribed for many diseases. Anticoagulation medications include:

• warfarin (Coumadin)
• Heparin
• enoxaparin (Lovenox)
• rivaroxaban (Xarelto)
• edoxaban (Savaysa)
• dabigatran (Pradaxa)

Antiplatelet medications include:

• Aspirin
• clopidogrel (Plaxiv)
• prasugrel (Effient)
• ticagrelor (Brillanta)

Some people have genetic or inborn errors of the blood clotting system. Minor injuries may cause major bleeding in these people. Hemophilia and von Willebrand disease are two examples of hereditary clotting disorders.