Bleeding causes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]}

## Overview

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## Definition of Multivessel Disease

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For AEGIS-II inclusion criteria #5, multivessel disease criteria can be met by findings on the cardiac catheterization for the index MI, a prior cardiac catheterization, or both:

* Index MI cardiac catheterization: 50% or greater stenosis of the left main or at least 2 coronary artery territories (LAD, LCX, RCA) (prior to any interventions performed)
* Prior cardiac catheterization: 50% or greater stenosis of left main or at least 2 coronary artery territories (LAD, LCx, RCA) (prior to any interventions performed)
* Both: Index MI cardiac catheterization with 1 vessel with 50% or greater stenosis (prior to any interventions performed) AND prior PCI of at least 1 vessel different from index MI vessel
* Prior multivessel CABG

Multivessel disease requires a 50% or greater stenosis in at least 2 of the 3 major epicardial artery territories (LAD, LCx, RCA) or the left main vessel. Branch vessel disease may qualify as part of the territory of that branch vessel (for example, a diagonal vessel is considered part of the LAD territory). For the purpose of this study, the ramus is considered part of the Left Circumflex artery territory. If a branch vessel is used as a qualifying vessel, that branch should be of large enough size to potentially undergo revascularization if clinically indicated, e.g. >2mm vessel size.

## Causes

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* Hematemesis \- vomiting fresh blood
* Hemoptysis \- coughing up blood from the lungs
* Hematochezia \- rectal blood
* Hematuria \- blood in the urine from urinary bleeding
* Intracranial hemorrhage \- bleeding in the skull.
* Cerebral hemorrhage \- a type of intracranial hemorrhage, bleeding within the brain tissue itself.
* Intracerebral hemorrhage \- bleeding in the brain caused by the rupture of a blood vessel within the head. See also hemorrhagic stroke.
* Subarachnoid hemorrhage (SAH) implies the presence of blood within the subarachnoid space from some pathologic process. The common medical use of the term SAH refers to the nontraumatic types of hemorrhages, usually from rupture of a berry aneurysm or arteriovenous malformation(AVM). The scope of this article is limited to these nontraumatic hemorrhages.
* Pulmonary hemorrhage
* Vaginal bleeding
* Postpartum hemorrhage
* Breakthrough bleeding
* Ovarian bleeding. This is a potentially catastrophic and not so rare complication among lean patients with polycystic ovary syndrome undergoing transvaginal oocyte retrieval.[1]
* Upper gastrointestinal bleed
* Suicide: Exsanguination is a suicide method caused by cutting of arteries, notably: carotid, radial, ulnar, and femoral arteries.
* Trauma: Injury or trauma can cause exsanguination if bleeding is not stymied. It is the most common cause of deaths on the battlefield (though the most common cause of death from battle is infection). Non-battlefield causes can include partial or complete amputation from use of circular saws (e.g., hand-held circular saw, radial arm saw, table saw).
* Internal hemorrhage: Patients can develop catastrophic internal hemorrhages, such as from a bleeding peptic ulcer or splenic hemorrhage, which can cause exsanguination even without any external bleeding. It is a relatively common cause of unexpected, sudden death in patients who seemed previously well.
* Alcoholism: Alcoholics can also suffer from exsanguination. Thin-walled dilated veins just below the lower esophageal mucosa called esophageal varices may ulcerate or be torn ("Mallory-Weiss syndrome") during the violent retching of the alcoholic leading to massive bleeding and sometimes exsanguination.
* Retroperitoneal hematoma
* Ruptured aortic aneurysm
* Ruptured abdominal aortic aneurysm

### Traumatic

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Traumatic bleeding is caused by some type of injury. There are different types of wounds which may cause traumatic bleeding. These include:

* Abrasion \- Also called a graze, this is caused by transverse action of a foreign object against the skin, and usually does not penetrate below the epidermis
* Excoriation \- In common with Abrasion, this is caused by mechanical destruction of the skin, although it usually has an underlying medical cause
* Hematoma \- (also called a blood tumor) - caused by damage to a blood vessel that in turn causes blood to collect under the skin.
* Laceration \- Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth. In some instances, this can also be used to describe an incision.
* Incision \- A cut into a body tissue or organ, such as by a scalpel, made during surgery.
* Puncture Wound \- Caused by an object penetrated the skin and underlying layers, such as a nail, needle or knife
* Contusion \- Also known as a bruise, this is a blunt trauma damaging tissue under the surface of the skin
* Crushing Injuries \- caused by a great or extreme amount of force applied over a long period of time. The extent of a crushing injury may not immediately present itself.
* Gunshot wounds \- Caused by a projectile weapon, this may include two external wounds (entry and exit) and a contiguous wound between the two

The pattern of injury, evaluation and treatment will vary with the mechanism of the injury. Blunt trauma causes injury via a shock effect; delivering energy over an area. Wounds are often not straight and unbroken skin may hide significant injury. Penetrating trauma follows the course of the injurious device. As the energy is applied in a more focused fashion, it requires less energy to cause significant injury. Any body organ, including bone and brain, can be injured and bleed. Bleeding may not be readily apparent; internal organs such as the liver, kidney and spleen may bleed into the abdominal cavity. The only apparent signs may come with blood loss. Bleeding from a bodily orifice, such as the rectum, nose, ears may signal internal bleeding, but cannot be relied upon. Bleeding from a medical procedure also falls into this category.

### Due to Underlying Medical Conditions

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Medical bleeding is that associated with an increased risk of bleeding due to an underlying medical condition. It will increase the risk of bleeding related to underlying anatomic deformities, such as weaknesses in blood vessels (aneurysm or dissection), arteriovenous malformation, ulcerations. Similarly, other conditions that disrupt the integrity of the body such as tissue death, cancer, or infection may lead to bleeding.

The underlying scientific basis for blood clotting and hemostasis is discussed in detail in the articles, Coagulation, haemostasis and related articles. The discussion here is limited to the common practical aspects of blood clot formation which manifest as bleeding.

Certain medical conditions can also make patients susceptible to bleeding. These are conditions that affect the normal "hemostatic" functions of the body. Hemostasis involves several components. The main components of the hemostatic system include platelets and the coagulation system.

Platelets are small blood components that form a plug in the blood vessel wall that stops bleeding. Platelets also produce a variety of substances that stimulate the production of a blood clot. One of the most common causes of increased bleeding risk is exposure to non-steroidal anti-inflammatory drugs (or "NSAIDs"). The prototype for these drugs is aspirin, which inhibits the production of thromboxane. NSAIDs inhibit the activation of platelets, and thereby increase the risk of bleeding. The effect of aspirin is irreversible; therefore, the inhibitory effect of aspirin is present until the platelets have been replaced (about ten days). Other NSAIDs, such as "ibuprofen" (Motrin) and related drugs, are reversible and therefore, the effect on platelets is not as long-lived.

There are several named coagulation factors that interact in a complex way to form blood clots, as discussed in the article on coagulation. Deficiencies of coagulation factors are associated with clinical bleeding. For instance, deficiency of Factor VIII causes classic Hemophilia A while deficiencies of Factor IX cause "Christmas disease"(hemophilia B). Antibodies to Factor VIII can also inactivate the Factor VII and precipitate bleeding that is very difficult to control. This is a rare condition that is most likely to occur in older patients and in those with autoimmune diseases. von Willebrand disease is another common bleeding disorder. It is caused by a deficiency of or abnormal function of the "von Willebrand" factor, which is involved in platelet activation. Deficiencies in other factors, such as factor XIII or factor VII are occasionally seen, but may not be associated with severe bleeding and are not as commonly diagnosed.

In addition to NSAID-related bleeding, another common cause of bleeding is that related to the medication, warfarin ("Coumadin" and others). This medication needs to be closely monitored as the bleeding risk can be markedly increased by interactions with other medications. Warfarin acts by inhibiting the production of Vitamin K in the gut. Vitamin K is required for the production of the clotting factors, II, VII, IX, and X in the liver. One of the most common causes of warfarin-related bleeding is taking antibiotics. The gut bacteria make vitamin K and are killed by antibiotics. This decreases vitamin K levels and therefore the production of these clotting factors.

Deficiencies of platelet function may require platelet transfusion while deficiciencies of clotting factors may require transfusion of either fresh frozen plasma of specific clotting factors, such as Factor VIII for patients with hemophilia.

### Causes by Organ System

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Cardiovascular | No underlying causes

|

Chemical/Poisoning | No underlying causes
Dental | No underlying causes
Dermatologic | No underlying causes
Drug Side Effect | Ceftazidime, Diclofenac (ophthalmic), diclofenac (patch), Ibrutinib, Omacetaxine, Sorafenib, Sunitinib, Tiagabine
Ear Nose Throat | No underlying causes
Endocrine | No underlying causes
Environmental | No underlying causes
Gastroenterologic | No underlying causes
Genetic | No underlying causes
Hematologic | No underlying causes
Iatrogenic | No underlying causes
Infectious Disease | No underlying causes
Musculoskeletal/Orthopedic | No underlying causes
Neurologic | No underlying causes
Nutritional/Metabolic | No underlying causes
Obstetric/Gynecologic | No underlying causes
Oncologic | No underlying causes
Ophthalmologic | No underlying causes
Overdose/Toxicity | No underlying causes
Psychiatric | No underlying causes
Pulmonary | No underlying causes
Renal/Electrolyte | No underlying causes
Rheumatology/Immunology/Allergy | No underlying causes
Sexual | No underlying causes
Trauma | No underlying causes
Urologic | No underlying causes
Miscellaneous | No underlying causes

## References

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1. ↑ Liberty G, Hyman JH, Eldar-Geva T, Latinsky B, Gal M, Margalioth EJ (2008). "Ovarian hemorrhage after transvaginal ultrasonographically guided oocyte aspiration: a potentially catastrophic and not so rare complication among lean patients with polycystic ovary syndrome". Fertil. Steril. 93 (3): 874–879. doi:10.1016/j.fertnstert.2008.10.028. PMID 19064264. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)

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