MISCELLANEOUS SITES OF BLEEDING

MISCELLANEOUS SITES OF BLEEDING: Excerpt from Differential Diagnosis in Primary Care

Bleeding from the Ear

This is not usually a serious condition. Anatomy is again applied to formulate a diagnosis. The blood may be from the external or middle ear and usually is caused by diseases of the skin or drum. Trauma is the most significant cause and is usually related to self-inflicted lacerations from digging at wax with hairpins or pencils, for example, which may occasionally rupture the eardrum. Children are prone to lodge foreign bodies in their ears. Skull fractures of the posterior fossa may present with bleeding from the ear. External otitis and otitis media may cause a bloody discharge, but this is not common. If the drum is ruptured by infection, there is usually bleeding from the ear. Carcinomas of the skin of the external canal may cause a bloody discharge and cholesteatomas will cause bleeding when they ulcerate through the tympanic membrane. Coagulation disorders rarely present with bleeding from the ear, in contrast to epistaxis and bleeding from the gums.

Bleeding from the gums

No anatomic breakdown is necessary here. The causes may be divided into local and systemic categories but by using the word VINDICATE one can cover all the etiologic categories adequately.

1. V—Vascular includes the hemorrhagic disorders, especially hemophilia, thrombocytopenia, heparin and warfarin (Coumadin) therapy, and fibrinogenopenia, as in DIC.
2. I—Inflammatory includes acute gingivitis, dental abscesses, pyorrhea, actinomycosis, or syphilis.
3. N—Neoplasms suggest both local neoplasms (e.g., odontoma, papillomas, and epulis) and systemic neoplasms (Hodgkin disease and leukemia).
4. D—Degenerative disorders include aplastic anemia and deficiencies such as scurvy and vitamin K deficiencies.
5. I—Intoxication recalls mercury, phosphorus, and diphenylhydantoin intoxication, in which the gums are usually severely hypertrophied as well.
6. C—Congenital conditions, other than congenital blood dyscrasias (e.g., sickle cell anemia), include erythema bullosum.
7. A—Autoimmune suggests thrombocytopenic purpura, Henoch purpura, and lupus erythematosus.
8. T—Trauma indicates bleeding from vigorous brushing or picking with a toothpick.
9. E—Endocrine disorders are not likely to cause bleeding except secondarily, as in diabetic-induced pyorrhea or the alveolar bone degeneration or dysplasia (osteotic) of hyperparathyroidism.

Gingivitis as part of a diffuse stomatitis may be seen in pemphigus, Stevens–Johnson syndrome, Vincent stomatitis (spirilla and bacilli fusiformis), and various other bacterial forms. The job of the clinician is to exclude the systemic causes and then refer the patient to a periodontist for evaluation and treatment of the local causes.

Bleeding from the breast, hemorrhagic discharge

Suspect a neoplasm, such as a ductal carcinoma (Paget disease), fibroadenosis, and ductal papillomas, unless proven otherwise. With a magnifying glass, one may be able to tell which of the 20 or so ducts is bleeding, but expressing one small segment at a time, working spirally, is also helpful.

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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