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Diseases » Hemorrhage » Causes
 

Causes of Hemorrhage

Contents
  1. Hemorrhage: Introduction
  2. List of Causes
  3. Drugs/substances (83 causes)
  4. Drug interaction (6238 causes)
  5. Hidden causes
  6. Excerpts from book chapters
  7. Complication causes
  8. Causes of symptoms
  9. News
  10. Related cause information

List of causes of Hemorrhage

Following is a list of causes or underlying conditions (see also Misdiagnosis of underlying causes of Hemorrhage) that could possibly cause Hemorrhage includes:

More causes: see full list of causes for Bleeding symptoms

Hemorrhage Causes: Book Excerpts

Hemorrhage as a complication of other conditions:

Other conditions that might have Hemorrhage as a complication may, potentially, be an underlying cause of Hemorrhage. Our database lists the following as having Hemorrhage as a complication of that condition:

Hemorrhage as a symptom:

Conditions listing Hemorrhage as a symptom may also be potential underlying causes of Hemorrhage. Our database lists the following as having Hemorrhage as a symptom of that condition:

Medications or substances causing Hemorrhage:

The following drugs, medications, substances or toxins are some of the possible causes of Hemorrhage as a symptom. This list is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

  • Cytarabine Hydrochloride
  • Cytosar-U
  • Cefoperazone Sodium
  • Cefobid
  • Zefazone
  • more drugs...»

See full list of 83 medications causing Hemorrhage


Drug interactions causing Hemorrhage:

When combined, certain drugs, medications, substances or toxins may react causing Hemorrhage as a symptom.

The list below is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

  • Ticlopidine and aspirin interaction
  • Ticlid and aspirin interaction
  • Olanzapine and fluoxetine and aspirin interaction
  • Zyprexa and fluoxetine and aspirin interaction
  • Zyprexa Zydis and fluoxetine and aspirin interaction
  • more interactions...»

See full list of 6238 drug interactions causing Hemorrhage

Medical news summaries relating to Hemorrhage:

The following medical news items are relevant to causes of Hemorrhage:

Related information on causes of Hemorrhage:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Hemorrhage may be found in:

Causes of Hemorrhage: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Hemorrhage.

Abnormal Uterine Bleeding: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Endometrial hyperplasia
    –Endogenous estrogen excess (e.g., obesity, tumor)
    –Exogenous estrogen
    –DUB is a diagnosis of exclusion (usually not cyclic, occurs irregularly throughout the menstrual cycle)
  • Polycystic ovarian syndrome
  • Hypo- or hyperthyroidism
    • Endometrial atrophy
      –Caused by long-term progestin or oral contraceptive use
    • Anatomic or structural lesions
      –Uterine leiomyoma (fibroids)
      –Foreign body (often intrauterine device)
      –Cervical or uterine polyps
    • Pelvic infection (cervicitis, pelvic inflammatory disease)
    • Hypothalamic lesion
    • Hyperprolactinemia
    • Medications (e.g., exogenous estrogen, phenothiazines, reserpine)
    • Coagulation disorders
      –Platelet dysfunction: Thrombocytopenia, leukemia, medications (e.g., aspirin, NSAIDs)
      –Clotting factor abnormality: Von Willebrand's disease, hemophilia, hepatic or renal disease, anticoagulant use
      • Complications of pregnancy
        –Spontaneous abortion (miscarriage)
        –Ectopic pregnancy
        –Placenta previa
        –Placental abruption
        • Endometrial cancer
          –Risk factors include older age, chronic anovulation, obesity, hypertension, DM, and unopposed estrogen
        • Systemic disease (e.g., HIV, hepatic disease, renal disease)
        • Nonuterine bleeding
          –Vaginal (tear, trauma, or cancer)
          –Cervical (trauma or cancer)
          –Urinary (UTI or cancer)
          –Rectal (bleeding, trauma, fissure, or cancer)
        • Other malignancy (ovarian or uterine tumor, sarcoma)
        • Endometrioma

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Bleeding (Excessive): Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Drugs (e.g., aspirin, heparin, warfarin, alcohol, chemotherapy)
  • Senile purpura
  • Uremia
  • Liver disease
  • HIV
    –Platelets decrease in number due to infection of megakaryocytes
  • Severe vitamin K deficiency
  • DIC
  • HSP
  • Von Willebrand's disease
  • Hemophilia
  • ITP
  • Heparin-induced thrombocytopenia
  • Myelodysplasia
  • TTP-HUS
  • Leukemia
  • Hereditary hemorrhagic telangiectasia
  • Ehlers-Danlos syndrome
  • Bernard-Soulier syndrome
  • Arteriovenous malformation
  • Pancytopenia
  • Isolated factor deficiency

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

GI Bleeding - Hematemesis: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Peptic ulcer disease is the most common etiology of upper GI bleeding
    –Increased risk with NSAID, steroid, or alcohol use; smoking, stress (e.g., ICU and trauma patients), or infections (Helicobacter pylori, CMV, herpes simplex virus)
  • Nasopharyngeal or oropharyngeal sources of bleeding
  • Esophageal etiologies
    –Esophageal varices (common in alcoholics and cirrhotic patients)
    –Erosive esophagitis: Infectious (e.g., Candida, HSV, CMV), corrosive ingestion, or pill-induced
    –Esophageal or gastric carcinoma
    –Esophageal or gastric polyps
  • Gastric etiologies
    –Gastric ulcer
    –Gastritis
    –Arteriovenous malformations: Osler-Weber-Rendu syndrome (cutaneous telangectasias, recurrent nosebleeds), idiopathic angiomas, radiation-induced telangectasias, blue rubber bleb nevus syndrome
    –Mallory-Weiss tear secondary to repetitive vomiting
    –Dieulafoy's lesion: Erosion of the mucosa overlying an artery in the stomach causes necrosis of the arterial wall and resultant hemorrhage
    –Gastric varices: Secondary to splenic vein thrombosis
    –Benign or malignant tumors
  • Duodenal etiologies
    –Duodenal ulcer
    –Erosion of a pancreatic tumor into the duodenum
    –Aortoenteric fistula: Must be suspected in any patient with a known aortic graft (e.g., prior AAA repair or occlusive aortic disease)
  • Systemic etiologies
    –Coagulopathies (e.g., hemophilia)
    –Thrombocytopenia
    –Anticoagulation therapy (e.g., warfarin)
    –Hereditary hemorrhagic telangiectasia
    –Leukemia
    –Connective tissue disease

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

GI Bleeding - Melena & Hematochezia: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Anatomic lesions
    –Diverticular bleeding causes 30–50% of all cases of massive rectal bleeding; associated with mild, crampy pain, but can be painless; not associated with diverticulitis
    –Meckel's diverticulum
  • Vascular lesions
    –Angiodysplasia (arteriovenous malformation): Most frequent cause in older patients; bleeding tends to be episodic and self-limited; painless; increased risk with increased age
  • Neoplastic lesions
    –Colon cancer or polyps: Causes 10% of cases of lower GI bleeding in patients >50 years; generally low-grade, recurrent bleeding
    –Rectal cancer
    –Small bowel tumors
  • Inflammatory lesions
    –Colitis/ulcers (e.g., inflammatory bowel disease, infectious colitis, ischemic colitis, radiation colitis)
    –Ischemic colitis generally presents with abdominal pain
    –Ulcerative colitis more associated with gross rectal bleeding
    –Crohn's disease more commonly associated with diffuse crampy abdominal pain, whereas ulcerative colitis is more localized to left lower quadrant
  • Anorectal lesions
    –Hemorrhoids are the most common cause of rectal bleeding in patients younger than 50 years old; usually painless bleeding
    –Fissures
    –Polyps
    –Idiopathic rectal ulcers
  • Aortoenteric fistula: Must be suspected in any patient with a known aortic graft (e.g., prior aortic aneurysm repair or occlusive aortic disease)
  • Idiopathic in up to 15% of cases
  • Upper GI bleeding
  • Systemic bleeding disorders (e.g., hemophilia, excessive anticoagulation, thrombocytopenia)

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Retinal Hemorrhage: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

  • It is critical to realize that hemorrhages do not progress but represent altered structure, and as such may affect acuity
  • Nonaccidental trauma must be the first etiology considered
  • Pigmented lesions of the retina including choroidal nevi, congenital hypertrophy of the retinal pigment epithelium, retinal pigment epithelial hyperplasia
  • Diabetic retinopathy is characterized by dot/blot, flame, preretinal, vitreous hemorrhages
  • Hypertensive retinopathy is typically accompanied by signs of hypoxia, e.g., cotton wool spots and optic disc swelling
  • May be associated with any systemic vascular disease or collagen vascular disease (e.g., systemic lupus erythematosus)
    • Vein occlusion
      –Occlusion of a central vein may involve the entire retina, occlusion of one branch vein involves a section of the retina
  • Peripheral retinal hemorrhaging may be associated with vascular insufficiency due to carotid stenosis
  • May be associated with optic disc swelling
  • Traumatic truncal injury may create intraretinal hemorrhages called Purtscher lesions
  • Intracranial hemorrhage may dissect forward to surround optic nerve (Terson phenomenon)
  • Blood dyscrasias, anemias, leukemias, sickle cell, ocular sarcoidosis, Behçet disease, Eales disease may cause retinopathy
  • If sudden loss of vision is associated, wet macular degeneration, macular hemorrhage of histoplasmosis, preretinal hemorrhage, or vitreous hemorrhage may be the etiology
  • Retinal vascular tumors, which may have an associated neurologic aneurysm
  • HIV retinopathy presents with hemorrhage as first sign but may progress to involve and destroy vision

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Abnormal Vaginal Bleeding: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

  • Dysfunctional uterine bleeding (DUB)
    –Physiologic anovulation is normal for up to 2 years after menarche
    –Androgen excess
    –Functional ovarian hyperandrogenism, or polycystic ovary syndrome, is common in adolescence
    –Estrogen excess
    –Hyperprolactinemia
    –Hypothyroidism
    –Early premature ovarian failure
  • Luteal phase defects
    • Pregnancy disorders
      –Spontaneous abortion (threatened, missed, incomplete)
      –Molar pregnancy
      –Ectopic pregnancy
    • True vaginal bleeding
      –Trauma (including sexual abuse)
      –Vaginal sarcoma (sarcoma botyroides)
      –Foreign body (more common in the younger child)
  • Menorrhagia
    –Idiopathic: Most common cause of menorrhagia in adolescents
    –Coagulopathy/bleeding disorder (e.g., thrombocytopenia, von Willebrand disease, factor IX deficiency)
    –Uterine polyp or neoplasm
    • Hematuria mistaken for vaginal bleeding
      –Urethral prolapse
      –Urinary tract infection
    • Excoriations due to pruritus
    • Vulvovaginitis
      –Trichomonas
      –Chlamydia
      –Gonorrhea
      –Pinworms (rare)
    • Cervical lesions
      –Cervical polyp
      –Hemangioma
      –Cervical friability

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Gum bleeding [Gingival bleeding]: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Agranulocytosis

Spontaneous gum bleeding and other systemic hemorrhages may occur in agranulocytosis, which typically causes progressive fatigue and weakness, followed by signs of infection, such as a fever and chills. Inspection may reveal oral and perianal lesions, which are usually rough edged with a gray or black membrane.

Aplastic anemia

In aplastic anemia, profuse or scant gum bleeding may follow trauma. Other signs of bleeding, such as epistaxis and ecchymoses, are also characteristic. The patient exhibits progressive weakness and fatigue, shortness of breath, a headache, pallor and, possibly, a fever. Eventually, tachycardia and signs of heart failure, such as jugular vein distention and dyspnea, also develop.

Ehlers-Danlos syndrome

In Ehlers-Danlos syndrome, gums bleed easily after toothbrushing. Easy bruising and other signs of abnormal bleeding are also typical. The skin is fragile and hyperelastic; joints are hyperextendible.

Gingivitis

Reddened and edematous gums are characteristic of gingivitis. The gingivae between the teeth become bulbous and bleed easily with slight trauma. However, with acute necrotizing ulcerative gingivitis, bleeding is spontaneous and the gums become so painful that the patient may be unable to eat. A characteristic grayish yellow pseudomembrane develops over punched-out gum erosions. Offensive halitosis is typical and may be accompanied by a headache, malaise, fever, and cervical adenopathy.

Hemophilia

Hemorrhage occurs from many sites in the oral cavity, especially the gums. Mild hemophilia causes easy bruising, hematomas, epistaxis, bleeding gums, and prolonged bleeding during even minor surgery and up to 8 days afterward. Moderate hemophilia produces more frequent episodes of abnormal bleeding and occasional bleeding into the joints, which may cause swelling and pain. Severe hemophilia causes spontaneous or severe bleeding after minor trauma, possibly resulting in large subcutaneous and intramuscular hematomas. Bleeding into joints and muscles causes pain, swelling, extreme tenderness and, possibly, permanent deformity. Bleeding near peripheral nerves causes peripheral neuropathies, pain, paresthesia, and muscle atrophy. Signs of anemia and a fever may follow bleeding. Severe blood loss may lead to shock and death.

Hereditary hemorrhagic telangiectasia

Hereditary hemorrhagic telangiectasia is characterized by red to violet spiderlike hemorrhagic areas on the gums, which blanch on pressure and bleed spontaneously. These telangiectases may also occur on the lips, buccal mucosa, and palate; on the face, ears, scalp, hands, arms, and feet; and under the nails. Epistaxis commonly occurs early and is difficult to control. Hemoptysis and signs of GI bleeding may develop.

Leukemia

Easy gum bleeding, which is an early sign of acute monocytic, lymphocytic, or myelocytic leukemia, is accompanied by gum swelling, necrosis, and petechiae. The soft, tender gums appear glossy and bluish. Acute leukemia causes severe prostration marked by a high fever and bleeding tendencies, such as epistaxis and prolonged menses. It may also cause dyspnea, tachycardia, palpitations, and abdominal or bone pain. Later effects may include confusion, headaches, vomiting, seizures, papilledema, and nuchal rigidity.

Chronic leukemia usually develops insidiously, producing less-severe bleeding tendencies. Other effects may include anorexia, weight loss, a low-grade fever, chills, skin eruptions, and an enlarged spleen, tonsils, and lymph nodes. Signs of anemia, such as fatigue and pallor, may occur.

Pemphigoid (benign mucosal)

Most common in women between ages 40 and 50, pemphigoid typically causes thick-walled gum lesions that rupture, desquamate, and then bleed easily. Extensive scars form with healing, and the gums remain red for months. Lesions may also develop on other parts of the oral mucosa, conjunctiva and, less commonly, the skin. Secondary fibrous bands may lead to dysphagia, hoarseness, or blindness.

Periodontal disease

Gum bleeding typically occurs after chewing, toothbrushing, or gum probing, but may also occur spontaneously. As gingivae separate from the bone, pus-filled pockets develop around the teeth; occasionally, pus can be expressed. Other findings include an unpleasant taste with halitosis, facial pain, loose teeth, and dental calculi and plaque.

Polycythemia vera

In polycythemia vera, engorged gums ooze blood after even slight trauma. This disorder usually turns the oral mucosa — especially the gums and tongue — a deep red-violet. Among associated findings are a headache, dyspnea, dizziness, fatigue, paresthesia, tinnitus, double or blurred vision, aquagenic pruritus, epigastric distress, weight loss, increased blood pressure, ruddy cyanosis, ecchymosis, and hepatosplenomegaly.

Thrombocytopenia

Blood usually oozes between the teeth and gums; however, severe bleeding may follow minor trauma. Associated signs of hemorrhage include large blood-filled bullae in the mouth, petechiae, ecchymosis, epistaxis, and hematuria. Malaise, fatigue, weakness, and lethargy eventually develop.

Thrombocytopenic purpura (idiopathic)

Profuse gum bleeding occurs in idiopathetic thrombocytopenic purpura. Its classic feature, however, is spontaneous hemorrhagic skin lesions that range from pinpoint petechiae to massive hemorrhages. The patient has a tendency to bruise easily, develops petechiae on the oral mucosa, and may exhibit melena, epistaxis, or hematuria.

Vitamin K deficiency

The first sign of vitamin K deficiency is usually gums that bleed when the teeth are brushed. Other signs of abnormal bleeding, such as ecchymosis, epistaxis, and hematuria, may also occur. GI bleeding may produce hematemesis and melena; intracranial bleeding may cause a decreased level of consciousness and focal neurologic deficits.

Other causes

Drugs

Warfarin and heparin interfere with blood clotting and may cause prolonged gum bleeding. Abuse of aspirin and nonsteroidal anti-inflammatory drugs may alter platelets, producing bleeding gums. Localized gum bleeding may also occur with mucosal “aspirin burn” caused by dissolving aspirin near an aching tooth.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Vaginal bleeding, postmenopausal: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Atrophic vaginitis

When bloody staining occurs, it usually follows coitus or douching. Characteristic white, watery vaginal discharge may be accompanied by pruritus, dyspareunia, and a burning sensation in the vagina and labia. Sparse pubic hair, a pale vagina with decreased rugae and small hemorrhagic spots, clitoral atrophy, and shrinking of the labia minora may also occur.

Cervical cancer

Early invasive cervical cancer causes vaginal spotting or heavier bleeding, usually after coitus or douching but occasionally spontaneously. Related findings include persistent, pink-tinged, and foul-smelling vaginal discharge and postcoital pain. As the cancer spreads, back and sciatic pain, leg swelling, anorexia, weight loss, hematuria, dysuria, rectal bleeding, and weakness may occur.

Cervical or endometrial polyps

Cervical or endometrial polyps are small, pedunculated growths that may cause spotting (possibly as a mucopurulent, pink discharge) after coitus, douching, or straining to defecate. Many endometrial polyps are asymptomatic, however.

Endometrial hyperplasia or cancer

Bleeding occurs early, can be brownish and scant or bright red and profuse, and usually follows coitus or douching. Bleeding later becomes heavier and more frequent, leading to clotting and anemia. Bleeding may be accompanied by pelvic, rectal, lower back, and leg pain. The uterus may be enlarged.

Ovarian tumors (feminizing)

Estrogen-producing ovarian tumors can stimulate endometrial shedding and cause heavy bleeding unassociated with coitus or douching. A palpable pelvic mass, increased cervical mucus, breast enlargement, and spider angiomas may be present.

Vaginal cancer

Characteristic spotting or bleeding may be preceded by a thin, watery vaginal discharge. Bleeding may be spontaneous but usually follows coitus or douching. A firm, ulcerated vaginal lesion may be present; dyspareunia, urinary frequency, bladder and pelvic pain, rectal bleeding, and vulvar lesions may develop later.

Other causes

Drugs

Unopposed estrogen replacement therapy is a common cause of abnormal vaginal bleeding. This can usually be reduced by adding progesterone (in women who haven’t had a hysterectomy) and by adjusting the patient’s estrogen dosage.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Abnormal premenopausal bleeding: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Causes of abnormal premenopausal bleeding vary with the type of bleeding:

❑ Oligomenorrhea and polymenorrhea usually result from anovulation due to an endocrine or systemic disorder.

❑ Menorrhagia usually results from local lesions, such as uterine leiomyomas, endometrial polyps, and endometrial hyperplasia. It may also result from endometritis, salpingitis, and anovulation.

❑ Hypomenorrhea results from local, endocrine, or systemic disorders, or from blockage due to partial obstruction by the hymen or to cervical obstruction.

❑ Cryptomenorrhea may result from an imperforate hymen or cervical stenosis.

❑ Metrorrhagia usually results from slight physiologic bleeding from the endometrium during ovulation but may also result from local disorders, such as uterine malignancy, cervical erosions, polyps (which tend to bleed after intercourse), or inappropriate estrogen therapy. Complications of pregnancy can also cause premenopausal bleeding. Such bleeding may be as mild as spotting or as severe as menorrhagia. (See Causes of abnormal premenopausal bleeding, page 954.)

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Dysfunctional uterine bleeding: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

DUB usually results from an imbalance in the hormonal-endometrial relationship, where persistent and unopposed stimulation of the endometrium by estrogen occurs. Disorders that cause sustained high estrogen levels are polycystic ovary syndrome, obesity, immaturity of the hypothalamic-pituitary-ovarian mechanism (in postpubertal teenagers), and anovulation (in women in their late 30s or early 40s).

In most cases of DUB, the endometrium shows no pathologic changes. However, in chronic unopposed estrogen stimulation (as from a hormone-producing ovarian tumor), the endometrium may show hyperplastic or malignant changes. DUB occurs in 20% of adolescents and in 40% of women older than age 40.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Hereditary hemorrhagic telangiectasia: Causes
(Professional Guide to Diseases (Eighth Edition))

Hereditary hemorrhagic telangiectasia is transmitted by autosomal dominant inheritance. It seldom skips generations. In its homozygous state, it may be lethal.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Postmenopausal bleeding: Causes
(Professional Guide to Diseases (Eighth Edition))

Postmenopausal bleeding may result from:

❑ exogenous estrogen, when administration is excessive or prolonged or when small amounts are given in the presence of a hypersensitive endometrium

❑ endogenous estrogen production, especially when levels are high, as in persons with estrogen-producing ovarian tumor; however, in some persons, even a slight fluctuation in estrogen levels may cause bleeding

❑ atrophic endometrium due to low estrogen levels

❑ atrophic vaginitis, usually triggered by trauma during coitus in the absence of estrogen production

❑ aging, which increases vascular vulnerability by thinning epithelial surfaces, increasing vascular fragility, producing degenerative tissue changes, and decreasing resistance to infections

❑ cervical or endometrial cancer (more common after age 60)

❑ adenomatous hyperplasia or atypical adenomatous hyperplasia (usually considered a premalignant lesion).

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Gum bleeding [Gingival bleeding]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Agranulocytosis

Spontaneous gum bleeding and other systemic hemorrhages may occur in this hematologic disorder, which typically causes progressive fatigue and weakness, followed by signs of infection, such as fever and chills. Inspection may reveal oral and perianal lesions, which are usually rough edged with a gray or black membrane.

Aplastic anemia

In this disorder, profuse or scant gum bleeding may follow trauma. Other signs of bleeding, such as epistaxis and ecchymosis, are also characteristic. The patient exhibits progressive weakness and fatigue, shortness of breath, headache, pallor and, possibly, fever. Eventually, tachycardia and signs of heart failure, such as jugular vein distention and dyspnea, also develop.

Cirrhosis

A late sign of cirrhosis, gum bleeding occurs with epistaxis and other bleeding tendencies. Other late effects include ascites, hepatomegaly, pruritus, and jaundice.

Ehlers-Danlos syndrome

In this congenital syndrome, gums bleed easily after toothbrushing. Easy bruising and other signs of abnormal bleeding are also typical. Skin is fragile and hyperelastic; joints are hyperextendible.

Giant cell epulis

This pedunculated granuloma, which occurs on the gums or alveolar process in front of the molars, is dark red and vascular, resembling a surface ulcer. Gums bleed easily with slight trauma.

Gingivitis

Reddened and edematous gums are characteristic of this disorder. The gingivae between the teeth become bulbous and bleed easily with slight trauma. However, with acute necrotizing ulcerative gingivitis, bleeding is spontaneous and the gums become so painful that the patient may be unable to eat. A characteristic grayish yellow pseudomembrane develops over punched-out gum erosions. Halitosis is typical and may be accompanied by headache, malaise, fever, and cervical adenopathy.

Hemophilia

Hemorrhage occurs from many sites in the oral cavity, especially the gums. Mild hemophilia causes easy bruising, hematomas, epistaxis, bleeding gums, and prolonged bleeding during even minor surgery and for up to 8 days afterward. Moderate hemophilia produces more frequent episodes of abnormal bleeding and occasional bleeding into the joints, which may cause swelling and pain. Severe hemophilia causes spontaneous or severe bleeding after minor trauma, possibly resulting in large subcutaneous and intramuscular hematomas. Bleeding into joints and muscles causes pain, swelling, extreme tenderness and, possibly, permanent deformity. Bleeding near peripheral nerves causes peripheral neuropathies, pain, paresthesia, and muscle atrophy. Signs of anemia and fever may follow bleeding. Severe blood loss may lead to shock and death.

Hereditary hemorrhagic telangiectasia

This disorder is characterized by red to violet spiderlike hemorrhagic areas on the gums, which blanch on pressure and bleed spontaneously. These telangiectases may also occur on the lips, buccal mucosa, and palate; on the face, ears, scalp, hands, arms, and feet; and under the nails. Epistaxis commonly occurs early and is difficult to control. Hemoptysis and signs of GI bleeding may develop.

Hypofibrinogenemia

In this rare disorder, the patient has frequent, spontaneous episodes of severe gum bleeding. Hematomas, ecchymosis, and epistaxis are also common. Signs of GI bleeding (such as hematemesis) and of CNS bleeding (such as focal neurologic deficits) may also occur.

Leukemia

An early sign of acute monocytic, lymphocytic, or myelocytic leukemia, easy gum bleeding is accompanied by gum swelling, necrosis, and petechiae. The soft, tender gums appear glossy and bluish. Acute leukemia causes severe prostration marked by high fever and bleeding tendencies, such as epistaxis and prolonged menses. It may also cause dyspnea, tachycardia, palpitations, and abdominal or bone pain. Later effects may include confusion, headaches, vomiting, seizures, papilledema, and nuchal rigidity.

Chronic leukemia usually develops insidiously, producing less severe bleeding tendencies. Other effects may include anorexia, weight loss, low-grade fever, chills, skin eruptions, and enlarged spleen, tonsils, and lymph nodes. Signs of anemia, such as fatigue and pallor, may occur.

Pemphigoid (benign mucosal)

Most common in women between ages 40 and 50, this autoimmune disorder typically causes thick-walled gum lesions that rupture, desquamate, and then bleed easily. Extensive scars form with healing, and the gums remain red for months. Lesions may also develop on other parts of the oral mucosa, the conjunctivae and, less often, the skin. Secondary fibrous bands may lead to dysphagia, hoarseness, or blindness.

Periodontal disease

Gum bleeding typically occurs after chewing, toothbrushing, or gum probing but may also occur spontaneously. As gingivae separate from the bone, pus-filled pockets develop around the teeth; occasionally, pus can be expressed. Other findings include unpleasant taste with halitosis, facial pain, loose teeth, and dental calculi and plaque.

Pernicious anemia

Gum bleeding and a sore tongue can make eating painful in this disorder whose other cardinal symptoms are weakness and paresthesia. The patient’s lips, gums, and tongue appear markedly pale, and his sclerae and skin are jaundiced. Other features are typically widespread, affecting the GI, cardiovascular, and central nervous systems, and include altered bowel and bladder habits, personality changes, ataxia, tinnitus, dyspnea, and tachycardia.

Polycythemia vera

In this disorder, engorged gums ooze blood after even a slight trauma. Polycythemia vera usually turns the oral mucosa—especially the gums and tongue—a deep red-violet. Associated findings include headache, dyspnea, dizziness, fatigue, paresthesia, tinnitus, diplopia or blurred vision, aquagenic pruritus, epigastric distress, weight loss, increased blood pressure, ruddy cyanosis, ecchymosis, and hepatosplenomegaly.

Pyogenic granuloma

Commonly affecting the gums, lips, tongue, and buccal mucosa, this granuloma may ulcerate and bleed spontaneously or with slight trauma. The lesion is pedunculated with a smooth or warty surface.

Thrombasthenia (familial)

This hereditary blood platelet disorder causes spontaneous bleeding from the oral cavity, especially the gums. The patient commonly displays purpura, epistaxis, hemarthrosis, and signs of GI bleeding, such as hematemesis and melena.

Thrombocytopenia

In this disorder, blood usually oozes between the teeth and gums; however, severe bleeding may follow minor trauma. Associated signs of hemorrhage include large blood-filled bullae in the mouth, petechiae, ecchymosis, epistaxis, and hematuria. Malaise, fatigue, weakness, and lethargy eventually develop.

Thrombocytopenic purpura (idiopathic)

Profuse gum bleeding occurs in this disorder. Its classic feature, though, is spontaneous hemorrhagic skin lesions that range from pinpoint petechiae to massive hemorrhages. The patient has a tendency to bruise easily, develops petechiae on the oral mucosa, and may exhibit melena, epistaxis, or hematuria.

Vitamin C deficiency (scurvy)

This deficiency causes swollen, spongy, tender gums that bleed easily. The gums between the teeth are red or purple. The teeth themselves become loose and may be surrounded by pockets filled with clotted blood. Other findings include muscle and joint pain, petechiae, ecchymosis, splinter hemorrhages in the nail beds, and ocular hemorrhages. Associated effects are anorexia, dry mouth, pallor, weakness, lethargy, insomnia, scaly skin, and psychological disturbances, such as depression or hysteria.

Vitamin K deficiency

The first sign of this deficiency is usually gums that bleed when the teeth are brushed. Other signs of abnormal bleeding, such as ecchymosis, epistaxis, and hematuria, may also occur. GI bleeding may produce hematemesis and melena; intracranial bleeding may cause decreased level of consciousness and focal neurologic deficits.

Other causes

Chemical irritants

Occupational exposure to benzene may irritate the gums, resulting in bleeding. Other signs of abnormal bleeding may accompany limb weakness and sensory changes.

Drugs

Warfarin and heparin interfere with blood clotting and may cause prolonged gum bleeding. Abuse of aspirin and nonsteroidal anti-inflammatory drugs may alter platelets, producing bleeding gums. Localized gum bleeding may also occur with mucosal “aspirin burn” caused by dissolving aspirin near an aching tooth.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Vaginal bleeding, postmenopausal: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Atrophic vaginitis

When bloody staining occurs in this disorder, it usually follows coitus or douching. The characteristic watery white vaginal discharge may be accompanied by pruritus, dyspareunia, and a burning sensation in the vagina and labia. Sparse pubic hair, a pale vagina with decreased rugae and small hemorrhagic spots, clitoral atrophy, and shrinking of the labia minora may also occur.

Cervical cancer

Early invasive cervical cancer causes vaginal spotting or heavier bleeding, usually after coitus or douching but occasionally spontaneously. Related findings include a persistent, pink-tinged, and foul-smelling vaginal discharge and postcoital pain. As the cancer spreads, back and sciatic pain, leg swelling, anorexia, weight loss, hematuria, dysuria, rectal bleeding, and weakness may occur.

Cervical or endometrial polyps

These small, pedunculated growths may cause spotting (possibly as a mucopurulent pink discharge) after coitus, douching, or straining at defecation. However, many endometrial polyps produce no symptoms.

Endometrial hyperplasia or cancer

Bleeding occurs early in these disorders; it can be brownish and scant or bright red and profuse, and usually follows coitus or douching. Bleeding later becomes heavier and more frequent, leading to clotting and anemia. It may be accompanied by pelvic, rectal, low back, and leg pain and an enlarged uterus.

Ovarian tumors (feminizing)

Estrogen-producing ovarian tumors can stimulate endometrial shedding and cause heavy bleeding that isn’t associated with coitus or douching. A palpable pelvic mass, increased cervical mucus, breast enlargement, and spider angiomas may be present.

Vaginal cancer

Characteristic spotting or bleeding may be preceded by a thin, watery vaginal discharge. Bleeding may be spontaneous but usually follows coitus or douching. A firm, ulcerated vaginal lesion may be present; dyspareunia, urinary frequency, bladder and pelvic pain, rectal bleeding, and vulvar lesions may develop later.

Other causes

Drugs

Unopposed estrogen replacement therapy is a common cause of abnormal vaginal bleeding. This can usually be reduced by adding progesterone (in women who haven’t had a hysterectomy) and by adjusting the patient’s estrogen dosage.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Hematochezia [Rectal bleeding]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Amyloidosis

Hematochezia occasionally occurs when this disorder affects the GI tract. Massive, rapid hematochezia may precipitate signs of shock, such as hypotension and tachycardia. Associated signs and symptoms include hypoactive or absent bowel sounds, abdominal pain, malabsorption, diarrhea, and renal disease. The patient may also have a stiff, enlarged tongue, resulting in dysarthria.

Anal fissure

Slight hematochezia characterizes this disorder; blood may streak the stools or appear on toilet tissue. Accompanying hematochezia is severe rectal pain that may make the patient reluctant to defecate, thereby causing constipation.

Angiodysplastic lesions

Most common in elderly patients, these arteriovenous lesions of the ascending colon typically cause chronic, bright red rectal bleeding. Occasionally, they may result in life-threatening blood loss and signs of shock, such as tachycardia and hypotension.

Anorectal fistula

Blood, pus, mucus, and occasionally stools may drain from this type of fistula. Other effects include rectal pain and pruritus.

Coagulation disorders

Patients with a coagulation disorder (such as thrombocytopenia or disseminated intravascular coagulation) may experience GI bleeding marked by moderate to severe hematochezia. Bleeding may also occur in other body systems, producing such signs as epistaxis and purpura. Associated findings vary with the specific coagulation disorder.

Colitis

Ischemic colitis commonly causes bloody diarrhea, especially in elderly patients. Rectal bleeding may be slight or massive and is usually accompanied by severe, cramping lower abdominal pain and hypotension. Other effects include abdominal tenderness, distention, and absent bowel sounds. Severe colitis may cause life-threatening hypovolemic shock and peritonitis.

Ulcerative colitis typically causes bloody diarrhea that may also contain mucus. Blood loss may be slight or massive and is preceded by mild to severe abdominal cramps. Associated signs and symptoms include fever, tenesmus, anorexia, nausea, vomiting, hyperactive bowel sounds and, occasionally, tachycardia. Weight loss and weakness occur late.

Colon cancer

Bright red rectal bleeding with or without pain is a telling sign, especially in cancer of the left colon. This type of tumor usually causes early signs of obstruction, such as rectal pressure, bleeding, and intermittent fullness or cramping. As the disease progresses, the patient also develops obstipation, diarrhea or ribbon-shaped stools, and pain that’s typically relieved by passage of stools or flatus. Stools are grossly bloody.

Cancer of the right colon may initially cause melena and abdominal aching, pressure, and dull cramps. As the disease progresses, the patient may also experience diarrhea, anorexia, weight loss, anemia, weakness and fatigue, vomiting, an abdominal mass, and signs of obstruction, such as abdominal distention and abnormal bowel sounds.

Colorectal polyps

These polyps are the most common cause of intermittent hematochezia in adults younger than age 60, but they don’t always produce symptoms. When located high in the colon, polyps may cause blood-streaked stools that yield a positive response when tested with guaiac. If the polyps are located closer to the rectum, they may bleed freely.

Crohn’s disease

Hematochezia is not a common sign of this disorder unless the perineum is involved. If rectal bleeding does occur, it’s likely to be massive. The chief clinical features of Crohn’s disease include fever, abdominal distention and pain with guarding, diarrhea, hyperactive bowel sounds, anorexia, nausea, and fatigue. Palpation may reveal a mass in the colon.

Diverticulitis

Most common in elderly patients, this disorder can suddenly cause mild to moderate rectal bleeding after the patient feels the urge to defecate. The bleeding may end abruptly or may progress to life-threatening blood loss with signs of shock. Associated signs and symptoms may include left-lower-quadrant pain that’s relieved by defecation, alternating episodes of constipation and diarrhea, anorexia, nausea and vomiting, rebound tenderness, and a distended tympanic abdomen.

Dysentery

Bloody diarrhea is common in infection with Shigella, Amoeba, and Campylobacter, but rare with Salmonella. Abdominal pain or cramps, tenesmus, fever, and nausea may also occur.

Esophageal varices (ruptured)

In this life-threatening disorder, hematochezia may range from slight rectal oozing to grossly bloody stools and may be accompanied by mild to severe hematemesis or melena. Signs of shock, such as tachycardia and hypotension, may follow or occasionally precede overt signs of bleeding. Typically, the patient has a history of chronic liver disease.

Food poisoning (staphylococcal)

The patient may have bloody diarrhea 1 to 6 hours after ingesting food toxins. Accompanying signs and symptoms, which last a few hours, include severe, cramping abdominal pain, nausea and vomiting, and prostration.

Hemorrhoids

Hematochezia may accompany external hemorrhoids, which typically cause painful defecation, resulting in constipation. Less painful internal hemorrhoids usually produce more chronic bleeding with bowel movements, which may eventually lead to signs of anemia, such as weakness and fatigue.

Leptospirosis

The severe form of this infection—Weil’s syndrome—produces hematochezia or melena along with other signs of bleeding, such as epistaxis and hemoptysis. The bleeding is typically preceded by a sudden frontal headache, severe thigh and lumbar myalgia, cutaneous hyperesthesia, and conjunctival suffusion. Bleeding is followed by chills, a rapidly rising fever, and perhaps nausea and vomiting. Fever, headache, and myalgia usually intensify and persist for weeks. Other findings may include right-upper-quadrant tenderness, hepatomegaly, and jaundice.

Peptic ulcer

Upper GI bleeding is a common complication in this disorder. The patient may display hematochezia, hematemesis, or melena, depending on the intensity and amount of bleeding. If the peptic ulcer penetrates an artery or vein, massive bleeding may precipitate signs of shock, such as hypotension and tachycardia. Other findings may include chills, fever, nausea and vomiting, and signs of dehydration, such as dry mucous membranes, poor skin turgor, and thirst. Most patients have a history of epigastric pain that’s relieved by foods or antacids; some also have a history of habitual use of tobacco, alcohol, or nonsteroidal anti-inflammatory drugs.

Rectal melanoma (malignant)

This rare form of rectal cancer typically causes recurrent rectal bleeding that arises from a painless, asymptomatic mass.

Small-intestine cancer

This disorder occasionally produces slight hematochezia or blood-streaked stools. Its characteristic features include colicky pain and postprandial vomiting. Other common signs and symptoms include anorexia, weight loss, and fever. Palpation may reveal abdominal masses.

Typhoid fever

About 10% of patients with typhoid fever develop hematochezia, which is occasionally massive. However, melena is more common. Both signs of bleeding occur late and may be accompanied by marked abdominal distention, diarrhea, significant weight loss, mental dullness, and profound fatigue. Earlier signs and symptoms are pathognomonic rose spots, headache, chills, fever, constipation, dry cough, conjunctivitis, and epistaxis.

Ulcerative proctitis

In this disorder, the patient typically has an intense urge to defecate but passes only bright red blood, pus, or mucus. Other common findings include acute constipation and tenesmus.

Other causes

Heavy metal poisoning

Bloody diarrhea is accompanied by cramping abdominal pain, nausea, and vomiting. Other signs may include tachycardia, hypotension, seizures, paresthesia, depressed or absent deep tendon reflexes, and an altered level of consciousness.

Tests

Certain procedures, especially colonoscopy, polypectomy, and proctosigmoidoscopy, may cause rectal bleeding. Bowel perforation is rare.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Purpura/Petechiae/Excessive Bleeding: Differential Overview
(Field Guide to Bedside Diagnosis)

Purpura

❑Trauma

❑Senile purpura

❑Drugs

❑Vasculitis

❑Vitamin K deficiency

❑Psychogenic purpura

❑Cholesterol emboli

❑Warfarin necrosis

❑Scurvy

❑Thrombotic thrombocytopenic purpura

❑Henoch-Schonlein purpura

❑Amyloidosis

Petechiae

❑Autoimmune thrombocytopenia

❑Bacteremia

❑Hypersplenism

Excessive Bleeding

❑Over-anticoagulation

❑Thrombocytopenia

❑von Willebrand disease

❑Circulating anticoagulant

❑Disseminated intravascular coagulation

❑Hemophilia

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Gastrointestinal Bleeding: Differential Overview
(Field Guide to Bedside Diagnosis)

Upper GI

❑ Peptic ulcer disease

❑ Gastritis

❑ Mallory-Weiss tear

❑ Esophageal varices

❑ Esophagitis

❑ Epistaxis

❑ Esophageal cancer

❑ Gastric cancer

Lower GI

❑ Infectious diarrhea

❑ Diverticular bleeding

❑ Hemorrhoids

❑ Anal fissure

❑ Inflammatory bowel disease

❑ Angiodysplasia

❑ Colon cancer

❑ Mesenteric ischemia

❑ Aortoenteric fistula

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Vaginal Bleeding: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Ovulatory bleeding

❑ Anovulatory bleeding

❑ Uterine leiomyoma

❑ Dysfunctional bleeding

❑ Threatened abortion

❑ Cervical erosion or polyp

❑ Perimenopause

❑ Retained products of gestation

❑ Ectopic pregnancy

❑ Oral contraceptives

❑ Hyperandrogenism

❑ Cervical cancer

❑ Endometrial cancer

❑ Anticoagulation therapy

❑ Thrombocytopenia

❑ Hypothalamic-pituitary-gonadal immaturity

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Vaginal bleeding, postmenopausal: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Atrophic vaginitis

When bloody staining occurs in atrophic vaginitis, it usually follows coitus or douching. Characteristic white, watery vaginal discharge may be accompanied by pruritus, dyspareunia, and a burning sensation in the vagina and labia. Sparse pubic hair, a pale vagina with decreased rugae and small hemorrhagic spots, clitoral atrophy, and shrinking of the labia minora may also occur.

Cervical cancer

Early invasive cervical cancer causes vaginal spotting or heavier bleeding, usually after coitus or douching but occasionally spontaneously. Related findings include persistent, pink-tinged, and foul-smelling vaginal discharge and postcoital pain. As the cancer spreads, back and sciatic pain, leg swelling, anorexia, weight loss, hematuria, dysuria, rectal bleeding, and weakness may occur.

Cervical or endometrial polyps

Cervical or endometrial polyps are small, pedunculated growths that may cause spotting (possibly as a mucopurulent, pink discharge) after coitus, douching, or straining at stool. Many endometrial polyps produce no symptoms, however.

Endometrial hyperplasia or cancer

With endometrial hyperplasia or cancer, bleeding occurs early, can be brownish and scant or bright red and profuse, and usually follows coitus or douching. Bleeding later becomes heavier and more frequent, leading to clotting and anemia. Bleeding may be accompanied by pelvic, rectal, lower back, and leg pain. The uterus may be enlarged.

Ovarian tumor (feminizing)

Estrogen-producing ovarian tumors can stimulate endometrial shedding and cause heavy bleeding unassociated with coitus or douching. A palpable pelvic mass, increased cervical mucus, breast enlargement, and spider angiomas may be present.

Vaginal cancer

With vaginal cancer, characteristic spotting or bleeding may be preceded by a thin, watery vaginal discharge. Bleeding may be spontaneous but usually follows coitus or douching. A firm, ulcerated vaginal lesion may be present; dyspareunia, urinary frequency, bladder and pelvic pain, rectal bleeding, and vulvar lesions may develop later.

Other causes

Drugs

Unopposed estrogen replacement therapy is a common cause of abnormal vaginal bleeding. This can usually be reduced by adding progesterone (in women who haven’t had a hysterectomy) and by adjusting the patient’s estrogen dosage.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Gum bleeding: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Agranulocytosis

Spontaneous gum bleeding and other systemic hemorrhages may occur in agranulocytosis, a hematologic disorder that typically causes progressive fatigue and weakness. Bleeding may be followed by signs of infection, such as fever and chills. Inspection may reveal oral and perianal lesions, which are usually rough edged with a gray or black membrane.

Aplastic anemia

In aplastic anemia, profuse or scant gum bleeding may follow trauma. Other signs of bleeding, such as epistaxis and ecchymoses, are also characteristic. The patient exhibits progressive weakness and fatigue, shortness of breath, headache, pallor and, possibly, fever. Eventually, tachycardia and signs of heart failure, such as jugular vein distention and dyspnea, also develop.

Cirrhosis

A late sign of cirrhosis, gum bleeding occurs with epistaxis and other bleeding tendencies. Additional late effects include ascites, hepatomegaly, pruritus, and jaundice. Other signs and symptoms include abdominal pain, anorexia, fatigue, nausea, vomiting, and weakness.

Gingivitis

Reddened and edematous gums are characteristic of gingivitis. The gingivae between the teeth become bulbous and bleed easily with slight trauma. However, with acute necrotizing ulcerative gingivitis, bleeding is spontaneous and the gums become so painful that the patient may be unable to eat. A characteristic grayish yellow pseudomembrane develops over punched-out gum erosions. Offensive halitosis is typical and may be accompanied by headache, malaise, fever, and cervical adenopathy.

Hemophilia

In hemophilia, hemorrhage occurs from many sites in the oral cavity, especially the gums. Mild hemophilia causes easy bruising, hematomas, epistaxis, bleeding gums, and prolonged bleeding during even minor surgery and up to 8 days afterward. Moderate hemophilia produces more frequent episodes of abnormal bleeding and occasional bleeding into the joints, which may cause swelling and pain. Severe hemophilia causes spontaneous or severe bleeding after minor trauma, possibly resulting in large subcutaneous and intramuscular hematomas. Bleeding into joints and muscles causes pain, swelling, and extreme tenderness and may cause permanent deformity. Bleeding near peripheral nerves causes peripheral neuropathies, pain, paresthesia, and muscle atrophy. Signs of anemia and fever may follow bleeding. Severe blood loss may lead to shock and death.

Leukemia

Easy gum bleeding is an early sign of acute monocytic, lymphocytic, or myelocytic leukemia that’s accompanied by gum swelling, necrosis, and petechiae. The soft, tender gums appear glossy and bluish. Acute leukemia causes severe prostration marked by high fever and bleeding tendencies, such as epistaxis and prolonged menses. It may also cause dyspnea, tachycardia, palpitations, and abdominal or bone pain. Later effects may include confusion, headaches, vomiting, seizures, papilledema, and nuchal rigidity.

Chronic leukemia usually develops insidiously, producing less-severe bleeding tendencies. Other effects may include anorexia, weight loss, low-grade fever, chills, skin eruptions, and enlarged spleen, tonsils, and lymph nodes. Signs of anemia, such as fatigue and pallor, may also occur.

Periodontal disease

Gum bleeding typically occurs after chewing, toothbrushing, or gum probing but may also occur spontaneously. As gingivae separate from the bone, pus-filled pockets develop around the teeth; occasionally, pus can be expressed. Other findings include unpleasant taste with halitosis, facial pain, loose teeth, and dental calculi and plaque.

Pernicious anemia

Gum bleeding and a sore tongue make eating painful for patients with pernicious anemia. Among other cardinal symptoms are weakness and paresthesia. The patient’s lips, gums, and tongue appear markedly pale, and his sclera and skin are jaundiced. Other features are typically widespread, affecting the GI, cardiovascular, and central nervous systems, and include altered bowel and bladder habits, personality changes, ataxia, tinnitus, dyspnea, and tachycardia.

Polycythemia vera

In polycythemia vera, engorged gums ooze blood after even slight trauma. Polycythemia vera usually turns the oral mucosa — especially the gums and tongue — a deep red-violet. Among associated findings are headache, dyspnea, dizziness, fatigue, paresthesia, tinnitus, double or blurred vision, aquagenic pruritus, epigastric distress, weight loss, increased blood pressure, ruddy cyanosis, ecchymosis, and hepatosplenomegaly.

Thrombocytopenia

With thrombocytopenia, blood usually oozes between the teeth and gums; however, severe bleeding may follow minor trauma. Associated signs of hemorrhage include large blood-filled bullae in the mouth, petechiae, ecchymosis, epistaxis, and hematuria. Malaise, fatigue, weakness, and lethargy eventually develop.

Thrombocytopenic purpura (idiopathic)

Profuse gum bleeding occurs in idiopathic thrombocytopenic purpura. Its classic feature, though, is spontaneous hemorrhagic skin lesions that range from pinpoint petechiae to massive hemorrhages. The patient has a tendency to bruise easily, develops petechiae on the oral mucosa, and may exhibit melena, epistaxis, or hematuria.

Vitamin K deficiency

The first sign of vitamin K deficiency is usually gums that bleed when the teeth are brushed. Other signs of abnormal bleeding, such as ecchymosis, epistaxis, and hematuria, may also occur. GI bleeding may produce hematemesis and melena; intracranial bleeding may cause decreased level of consciousness and focal neurologic deficits.

Other causes

Chemical irritants

Occupational exposure to benzene may irritate the gums, resulting in bleeding. Other signs of abnormal bleeding may accompany limb weakness and sensory changes.

Drugs

Warfarin and heparin interfere with blood clotting and may cause prolonged gum bleeding. Abuse of aspirin and nonsteroidal anti-inflammatory drugs may alter platelets, producing bleeding gums. Localized gum bleeding may also occur with mucosal “aspirin burn” caused by dissolving aspirin near an aching tooth.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Gastrointestinal Bleeding: Principal Causes of Gastrointestinal Bleeding
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  1. Uppergastrointestinal bleeding
    1. Nose
    2. Mouth and pharynx
    3. Esophagus
      1. Esophagitis
        1. Gastroesophageal reflux
        2. Caustic ingestion
        3. Infection
      2. Foreign body
      3. Varices
      4. Duplication
    4. Gastroesophageal junction
      1. Mallory-Weisstear
    5. Stomach
      1. Gastritis
      2. Ulcer
      3. Duplication
      4. Vascular malformation
      5. Neoplasm
    6. Duodenum
      1. Ulcer
      2. Foreign body
      3. Varices
      4. Duplication
      5. Vascular malformation
      6. Hemobilia
    7. Other
      1. Swallowed blood
      2. Coagulopathy
        1. Hemorrhagic disease of the newborn(vitamin K deficiency)
        2. Disseminated intravascular coagulation
      3. Drugs
  2. Lower gastrointestinal bleeding
    1. Intestine
      1. Cow milk/soyprotein sensitivity
      2. Necrotizing enterocolitis
      3. Infectious colitis
      4. Henoch-Schönlein purpura
      5. Intussusception
      6. Congenital aganglionic megacolon (Hirschsprungdisease)
      7. Meckel diverticulum
      8. Volvulus with malrotation
      9. Inflammatory bowel disease
      10. Intestinal polyps
        1. Solitaryjuvenile polyps/juvenile intestinal polyposis
        2. Adenomatous polyposis of the colon
        3. Peutz-Jeghers syndrome
        4. Benign lymphoid hyperplasia
        5. Duplication
        6. Vascular malformation
        7. Neoplasm
    2. Rectum and anus
      1. Anal fissure
      2. Trauma
      3. Sexual abuse
      4. Hemorrhoids
      5. Other
    3. Swallowed blood
    4. Coagulopathy
    5. Drugs
  3. Factitious bleeding

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Purpura and Bleeding: Principal Causes of Purpura and Bleeding
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  1. Lossof vascular integrity
    1. Trauma
    2. Infection
    3. Henoch-Schönlein purpura
    4. Drugs
    5. Langerhans histiocytosis
    6. Ehlers-Danlos syndrome
    7. Vitamin C deficiency
    8. Hereditary hemorrhagic telangiectasia(Osler-Rendu-Weber disease)
  2. Thrombocytopenia
    1. Increasedplatelet destruction
      1. Immune-mediated
        1. Neonatal alloimmune thrombocytopenia
        2. Maternal autoimmune thrombocytopenia
        3. Idiopathic thrombocytopenic purpura
        4. Collagen vascular disease
        5. Drug-induced thrombocytopenia
      2. Infection
      3. Hemolytic-uremic syndrome
      4. Thrombotic thrombocytopenic purpura
      5. Wiskott-Aldrich syndrome
    2. Decreased platelet production
      1. Infection
      2. Specific platelet disorders
        1. Congenitalamegakaryocytic thrombocytopenia
        2. Thrombocytopenia–absent radiisyndrome
      3. Bone marrow suppression (generalized)
      4. Bone marrow replacement
      5. Megaloblastic anemia
      6. Platelet sequestration
        1. Hypersplenism
        2. Large hemangiomas
  3. Abnormal platelet function
    1. Thrombasthenia(Glanzmann disease)
    2. Giant platelet syndrome (Bernard-Souliersyndrome)
    3. Storage pool deficiency
    4. Drugs
    5. Uremia
  4. Coagulation disorders
    1. Factordeficiencies
      1. VonWillebrand disease
      2. Factor VIII deficiency (hemophiliaA)
      3. Factor IX deficiency (hemophilia B,Christmas disease)
      4. Deficiencies of Factors I, II, V, VII,X, XI, and XIII
    2. Vitamin K deficiency
    3. Disseminated intravascular coagulation
    4. Liver disease
    5. Circulating anticoagulants

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Vaginal Bleeding: Principal Causes of Vaginal Bleeding
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  1. Beforenormal menarche
    1. Trauma
    2. Vulvovaginitis
    3. Foreign body
    4. Urethral prolapse
    5. Condyloma acuminata
    6. Exogenous hormone preparations
    7. Precocious puberty
    8. Premature menarche
    9. Hypothyroidism
    10. Genital tract tumors
  2. After menarche
    1. Trauma
    2. Vulvovaginitis
    3. Foreign body
    4. Pelvic inflammatory disease
    5. Cervicitis
    6. Cervical polyps
    7. Anovulatory cycles
    8. Ovulation
    9. Endometriosis
    10. Genital tract tumors
    11. Bleeding disorders
    12. Endocrine disorders
    13. Systemic diseases
    14. Drugs
    15. Complications of pregnancy

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Gum bleeding [Gingival bleeding]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Agranulocytosis.Spontaneous gum bleeding and other systemic hemorrhages may occur in agranulocytosis, which typically causes progressive fatigue and weakness, followed by signs of infection, such as a fever and chills. Inspection may reveal oral and perianal lesions, which are usually rough edged with a gray or black membrane.

Aplastic anemia.In aplastic anemia, profuse or scant gum bleeding may follow trauma. Other signs of bleeding, such as epistaxis and ecchymoses, are also characteristic. The patient exhibits progressive weakness and fatigue, shortness of breath, a headache, pallor and, possibly, a fever. Eventually, tachycardia and signs of heart failure, such as jugular vein distention and dyspnea, also develop.

Ehlers-Danlos syndrome.In Ehlers-Danlos syndrome, gums bleed easily after toothbrushing. Easy bruising and other signs of abnormal bleeding are also typical. The skin is fragile and hyperelastic; joints are hyperextendible.

Gingivitis.Reddened and edematous gums are characteristic of gingivitis. The gingivae between the teeth become bulbous and bleed easily with slight trauma. However, with acute necrotizing ulcerative gingivitis, bleeding is spontaneous and the gums become so painful that the patient may be unable to eat. A characteristic grayish yellow pseudomembrane develops over punched-out gum erosions. Offensive halitosis is typical and may be accompanied by a headache, malaise, fever, and cervical adenopathy.

Hemophilia.Hemorrhage occurs from many sites in the oral cavity, especially the gums. Mild hemophilia causes easy bruising, hematomas, epistaxis, bleeding gums, and prolonged bleeding during even minor surgery and up to 8 days afterward. Moderate hemophilia produces more frequent episodes of abnormal bleeding and occasional bleeding into the joints, which may cause swelling and pain. Severe hemophilia causes spontaneous or severe bleeding after minor trauma, possibly resulting in large subcutaneous and intramuscular hematomas. Bleeding into joints and muscles causes pain, swelling, extreme tenderness and, possibly, permanent deformity. Bleeding near peripheral nerves causes peripheral neuropathies, pain, paresthesia, and muscle atrophy. Signs of anemia and a fever may follow bleeding. Severe blood loss may lead to shock and death.

Hereditary hemorrhagic telangiectasia.Hereditary hemorrhagic telangiectasia is characterized by red to violet spiderlike hemorrhagic areas on the gums, which blanch on pressure and bleed spontaneously. These telangiectases may also occur on the lips, buccal mucosa, and palate; on the face, ears, scalp, hands, arms, and feet; and under the nails. Epistaxis commonly occurs early and is difficult to control. Hemoptysis and signs of GI bleeding may develop.

Leukemia.Easy gum bleeding, which is an early sign of acute monocytic, lymphocytic, or myelocytic leukemia, is accompanied by gum swelling, necrosis, and petechiae. The soft, tender gums appear glossy and bluish. Acute leukemia causes severe prostration marked by a high fever and bleeding tendencies, such as epistaxis and prolonged menses. It may also cause dyspnea, tachycardia, palpitations, and abdominal or bone pain. Later effects may include confusion, headaches, vomiting, seizures, papilledema, and nuchal rigidity.

Chronic leukemia usually develops insidiously, producing less-severe bleeding tendencies. Other effects may include anorexia, weight loss, a low-grade fever, chills, skin eruptions, and an enlarged spleen, tonsils, and lymph nodes. Signs of anemia, such as fatigue and pallor, may occur.

Pemphigoid (benign mucosal).Pemphigoid typically causes thick-walled gum lesions that rupture, desquamate, and then bleed easily. Extensive scars form with healing, and the gums remain red for months. Lesions may also develop on other parts of the oral mucosa, conjunctiva and, less commonly, the skin. Secondary fibrous bands may lead to dysphagia, hoarseness, or blindness.

Periodontal disease.With periodontal disease, gum bleeding typically occurs after chewing, toothbrushing, or gum probing, but may also occur spontaneously. As gingivae separate from the bone, pus-filled pockets develop around the teeth; occasionally, pus can be expressed. Other findings include an unpleasant taste with halitosis, facial pain, loose teeth, and dental calculi and plaque.

Polycythemia vera.In polycythemia vera, engorged gums ooze blood after even slight trauma. This disorder usually turns the oral mucosa—especially the gums and tongue—a deep red-violet. Among associated findings are a headache, dyspnea, dizziness, fatigue, paresthesia, tinnitus, double or blurred vision, aquagenic pruritus, epigastric distress, weight loss, increased blood pressure, ruddy cyanosis, ecchymosis, and hepatosplenomegaly.

Thrombocytopenia.With thrombocytopenia, blood usually oozes between the teeth and gums; however, severe bleeding may follow minor trauma. Associated signs of hemorrhage include large blood-filled bullae in the mouth, petechiae, ecchymosis, epistaxis, and hematuria. Malaise, fatigue, weakness, and lethargy eventually develop.

Thrombocytopenic purpura (idiopathic).Profuse gum bleeding occurs in idiopathetic thrombocytopenic purpura. Its classic feature, however, is spontaneous hemorrhagic skin lesions that range from pinpoint petechiae to massive hemorrhages. The patient has a tendency to bruise easily, develops petechiae on the oral mucosa, and may exhibit melena, epistaxis, or hematuria.

Vitamin K deficiency.The first sign of vitamin K deficiency is usually gums that bleed when the teeth are brushed. Other signs of abnormal bleeding, such as ecchymosis, epistaxis, and hematuria, may also occur. GI bleeding may produce hematemesis and melena; intracranial bleeding may cause a decreased level of consciousness and focal neurologic deficits.

Other causes

Drugs.Warfarin and heparin interfere with blood clotting and may cause prolonged gum bleeding. Abuse of aspirin and nonsteroidal anti-inflammatory drugs may alter platelets, producing bleeding gums. Localized gum bleeding may also occur with mucosal “aspirin burn” caused by dissolving aspirin near an aching tooth.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Vaginal bleeding, postmenopausal: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Atrophic vaginitis.When bloody staining occurs with atrophic vaginitis, it usually follows coitus or douching. Characteristic white, watery vaginal discharge may be accompanied by pruritus, dyspareunia, and a burning sensation in the vagina and labia. Sparse pubic hair, a pale vagina with decreased rugae and small hemorrhagic spots, clitoral atrophy, and shrinking of the labia minora may also occur.

Cervical cancer.Early invasive cervical cancer causes vaginal spotting or heavier bleeding, usually after coitus or douching but occasionally spontaneously. Related findings include persistent, pink-tinged, and foul-smelling vaginal discharge and postcoital pain. As the cancer spreads, back and sciatic pain, leg swelling, anorexia, weight loss, hematuria, dysuria, rectal bleeding, and weakness may occur and the drainage may become dark and malodorous.

Cervical or endometrial polyps.Cervical or endometrial polyps are small, pedunculated growths that may cause spotting (possibly as a mucopurulent, pink discharge) after coitus, douching, or straining to defecate. Many endometrial polyps produce no symptoms.

Endometrial hyperplasia or cancer.Bleeding occurs early with endometrial hyperplasia or cancer; it can be brownish and scant or bright red and profuse, and usually follows coitus or douching. Bleeding later becomes heavier and more frequent, leading to clotting and anemia. Bleeding may be accompanied by pelvic, rectal, lower back, and leg pain. The uterus may be enlarged.

Ovarian tumors (feminizing).Ovarian tumors producing estrogen can stimulate endometrial shedding and cause heavy bleeding unassociated with coitus or douching. A palpable pelvic mass, increased cervical mucus, breast enlargement, and spider angiomas may be present.

Vaginal cancer.Characteristic spotting or bleeding with vaginal cancer may be preceded by a thin, watery vaginal discharge. Bleeding may be spontaneous but usually follows coitus or douching. A firm, ulcerated vaginal lesion may be present; dyspareunia, urinary frequency, bladder and pelvic pain, rectal bleeding, and vulvar lesions may develop later.

Other causes

Drugs.Unopposed estrogen replacement therapy is a common cause of abnormal vaginal bleeding. This can usually be reduced by adding progesterone (in women who haven't had a hysterectomy) and by adjusting the patient's estrogen dosage.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Hematochezia [Rectal bleeding]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Anal fissure.Slight hematochezia characterizes anal fissure; blood may streak the stools or appear on toilet tissue. Accompanying hematochezia is severe rectal pain that may make the patient reluctant to defecate, thereby causing constipation.

Angiodysplastic lesions.Most common in elderly patients, these arteriovenous lesions of the ascending colon typically cause chronic, bright red rectal bleeding. Occasionally, this painless hematochezia may result in life-threatening blood loss and signs of shock, such as tachycardia and hypotension.

Coagulation disorders.Patients with a coagulation disorder (such as thrombocytopenia and disseminated intravascular coagulation) may experience GI bleeding marked by moderate to severe hematochezia. Bleeding may also occur in other body systems, producing such signs as epistaxis and purpura. Associated findings vary with the specific coagulation disorder.

Colitis.Ischemic colitis commonly causes bloody diarrhea, especially in elderly patients. Hematochezia may be slight or massive and is usually accompanied by severe, cramping lower abdominal pain and hypotension. Other effects include abdominal tenderness, distention, and absent bowel sounds. Severe colitis may cause life-threatening hypovolemic shock and peritonitis.

Ulcerative colitis typically causes bloody diarrhea that may also contain mucus. Hematochezia is preceded by mild to severe abdominal cramps and may cause slight to massive blood loss. Associated signs and symptoms include fever, tenesmus, anorexia, nausea, vomiting, hyperactive bowel sounds and, occasionally, tachycardia. Weight loss and weakness occur late.

Colon cancer.Bright red rectal bleeding with or without pain is a telling sign of colon cancer especially in cancer of the left colon.

Usually, a left colon tumor causes early signs of obstruction, such as rectal pressure, bleeding, and intermittent fullness or cramping. As the disease progresses, the patient also develops obstipation, diarrhea or ribbon-shaped stools, and pain, which is typically relieved by the passage of stools or flatus. Stools are grossly bloody.

Early tumor growth in the right colon may cause melena, abdominal aching, pressure, and dull cramps. As the disease progresses, the patient develops weakness and fatigue. Later, he may also experience diarrhea, anorexia, weight loss, anemia, vomiting, an abdominal mass, and signs of obstruction, such as abdominal distention and abnormal bowel sounds.

Colorectal polyps.Colorectal polyps are the most common cause of intermittent hematochezia in adults younger than age 60; however, sometimes such polyps produce no symptoms. When located high in the colon, polyps may cause blood-streaked stools. The stools yield a positive response when tested with guaiac. If the polyps are located closer to the rectum, they may bleed freely.

Diverticulitis.Most common in the elderly patient, diverticulitis can suddenly cause mild to moderate rectal bleeding after the patient feels the urge to defecate. The bleeding may end abruptly or may progress to life-threatening blood loss with signs of shock. Associated signs and symptoms may include left lower quadrant pain that's relieved by defecation, alternating episodes of constipation and diarrhea, anorexia, nausea and vomiting, rebound tenderness, and a distended tympanic abdomen.

Dysentery.Bloody diarrhea is common in infection with Shigella, Amoeba, and Campylobacter, but rare with Salmonella. Abdominal pain or cramps, tenesmus, a fever, and nausea may also occur.

Esophageal varices (ruptured).In esophageal varices, a life-threatening disorder, hematochezia may range from slight rectal oozing to grossly bloody stools and may be accompanied by mild to severe hematemesis or melena. This painless but massive hemorrhage may precipitate signs of shock, such as tachycardia and hypotension. In fact, signs of shock occasionally precede overt signs of bleeding. Typically, the patient has a history of chronic liver disease.

Food poisoning (staphylococcal).The patient may have bloody diarrhea 1 to 6 hours after ingesting food toxins. Accompanying signs and symptoms include severe, cramping abdominal pain; nausea and vomiting; and prostration, all of which last a few hours.

Hemorrhoids.Hematochezia may accompany external hemorrhoids, which typically cause painful defecation, resulting in constipation. Less painful internal hemorrhoids usually produce more chronic bleeding with bowel movements, which may eventually lead to signs of anemia, such as weakness and fatigue.

Leptospirosis.The severe form of leptospirosis—Weil's syndrome—produces hematochezia or melena along with other signs of bleeding, such as epistaxis and hemoptysis. The bleeding is typically preceded by a sudden frontal headache and severe thigh and lumbar myalgia that may be accompanied by cutaneous hyperesthesia. Conjunctival suffusion is indicative. Bleeding is followed by chills, a rapidly rising fever and, perhaps, nausea and vomiting. A fever, a headache, and myalgia usually intensify and persist for weeks. Other findings may include right upper quadrant tenderness, hepatomegaly, and jaundice.

Peptic ulcer.Upper GI bleeding is a common complication in peptic ulcer. The patient may display hematochezia, hematemesis, or melena, depending on the rapidity and amount of bleeding. If the peptic ulcer penetrates an artery or vein, massive bleeding may precipitate signs of shock, such as hypotension and tachycardia. Other findings may include chills, a fever, nausea and vomiting, and signs of dehydration, such as dry mucous membranes, poor skin turgor, and thirst. The patient typically has a history of epigastric pain that's relieved by foods or antacids; he may also have a history of habitually using tobacco, alcohol, or NSAIDs.

Ulcerative proctitis.Ulcerative proctitis typically causes an intense urge to defecate, but the patient passes only bright red blood, pus, or mucus. Other common signs and symptoms include acute constipation and tenesmus.

Other causes

Diagnostic tests.Certain procedures, especially colonoscopy, polypectomy, hemorrhoidectomy, and proctosigmoidoscopy, may cause rectal bleeding. Bowel perforation is rare.

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Source: Nursing: Interpreting Signs and Symptoms, 2007


 » Next page: Risk Factors for Hemorrhage

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