Bleeding

Bleeding, also known as a hemorrhage or haemorrhage, is blood escaping from the circulatory system from damaged blood vessels.[1] Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vagina or anus, or through a wound in the skin. Hypovolemia is a massive decrease in blood volume, and death by excessive loss of blood is referred to as exsanguination.[2] Typically, a healthy person can endure a loss of 10–15% of the total blood volume without serious medical difficulties (by comparison, blood donation typically takes 8–10% of the donor's blood volume).[3] The stopping or controlling of bleeding is called hemostasis and is an important part of both first aid and surgery. The use of cyanoacrylate glue to prevent bleeding and seal battle wounds was designed and first used in the Vietnam War. Today many medical treatments use a medical version of "super glue" instead of using traditional stitches used for small wounds that need to be closed at the skin level.

Bleeding
Other namesHemorrhaging, haemorrhaging
Bleeding finger
A bleeding wound in the finger
SpecialtyEmergency medicine

Classification

Eye hemorrhage
A subconjunctival hemorrhage is a common and relatively minor post-LASIK complication.
Linitis plastica 2
The endoscopic image of a type of stomach cancer known as linitis plastica. The leather bottle-like appearance can also cause bleeding as can be seen in this image.
Pulmonary haemorrhage - high mag
Micrograph showing abundant hemosiderin-laden alveolar macrophages (dark brown), as seen in a pulmonary hemorrhage. H&E stain.

Blood loss

Hemorrhaging is broken down into four classes by the American College of Surgeons' advanced trauma life support (ATLS).[4]

  • Class I Hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs and fluid resuscitation is not usually necessary.
  • Class II Hemorrhage involves 15-30% of total blood volume. A patient is often tachycardic (rapid heart beat) with a reduction in the difference between the systolic and diastolic blood pressures. The body attempts to compensate with peripheral vasoconstriction. Skin may start to look pale and be cool to the touch. The patient may exhibit slight changes in behavior. Volume resuscitation with crystalloids (Saline solution or Lactated Ringer's solution) is all that is typically required. Blood transfusion is not usually required.
  • Class III Hemorrhage involves loss of 30-40% of circulating blood volume. The patient's blood pressure drops, the heart rate increases, peripheral hypoperfusion (shock) with diminished capillary refill occurs, and the mental status worsens. Fluid resuscitation with crystalloid and blood transfusion are usually necessary.
  • Class IV Hemorrhage involves loss of >40% of circulating blood volume. The limit of the body's compensation is reached and aggressive resuscitation is required to prevent death.

This system is basically the same as used in the staging of hypovolemic shock.

Individuals in excellent physical and cardiovascular shape may have more effective compensatory mechanisms before experiencing cardiovascular collapse. These patients may look deceptively stable, with minimal derangements in vital signs, while having poor peripheral perfusion. Elderly patients or those with chronic medical conditions may have less tolerance to blood loss, less ability to compensate, and may take medications such as betablockers that can potentially blunt the cardiovascular response. Care must be taken in the assessment.

Massive hemorrhage

Although there is no universally accepted definition of massive hemorrhage; the following can be used to identify the condition: "(i) blood loss exceeding circulating blood volume within a 24-hour period, (ii) blood loss of 50% of circulating blood volume within a 3-hour period, (iii) blood loss exceeding 150 ml/min, or (iv) blood loss that necessitates plasma and platelet transfusion." [5]

World Health Organization

The World Health Organization made a standardized grading scale to measure the severity of bleeding.[6]

Grade 0 no bleeding
Grade 1 petechial bleeding;
Grade 2 mild blood loss (clinically significant);
Grade 3 gross blood loss, requires transfusion (severe);
Grade 4 debilitating blood loss, retinal or cerebral associated with fatality

Types

Causes

Bleeding arises due to either traumatic injury, underlying medical condition, or a combination.

Traumatic injury

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 - 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 that 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 period of time. The extent of a crushing injury may not immediately present itself.
  • Ballistic Trauma - Caused by a projectile weapon such as a firearm. 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, or ears may signal internal bleeding, but cannot be relied upon. Bleeding from a medical procedure also falls into this category.

Medical condition

"Medical bleeding" denotes hemorrhage as a result of an underlying medical condition (i.e. causes of bleeding that are not directly due to trauma). Blood can escape from blood vessels as a result of 3 basic patterns of injury:

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

Some medical conditions can also make patients susceptible to bleeding. These are conditions that affect the normal hemostatic (bleeding-control) functions of the body. Such conditions either are, or cause, bleeding diatheses. 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 nonsteroidal anti-inflammatory drugs (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. Another common bleeding disorder is Von Willebrand disease. It is caused by a deficiency 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 deficiencies of clotting factors may require transfusion of either fresh frozen plasma or specific clotting factors, such as Factor VIII for patients with hemophilia.

Imaging

Dioxaborolane chemistry enables radioactive fluoride (18F) labeling of red blood cells, which allows for positron emission tomography (PET) imaging of intracerebral hemorrhages.[8]

Etymology

The word "Haemorrhage" (or hæmorrhage; using the æ ligature) comes from Latin haemorrhagia, from Ancient Greek αἱμορραγία (haimorrhagía, “a violent bleeding”), from αἱμορραγής (haimorrhagḗs, “bleeding violently”), from αἷμα (haîma, “blood”) + -ραγία (-ragía), from ῥηγνύναι (rhēgnúnai, “to break, burst”).[9]

See also

References

  1. ^ "Bleeding Health Article". Healthline. Retrieved 2007-06-18.
  2. ^ "Dictionary Definitions of Exsanguination". Reference.com. Retrieved 2007-06-18.
  3. ^ "Blood Donation Information". UK National Blood Service. Archived from the original on 2007-09-28. Retrieved 2007-06-18.
  4. ^ Manning JE (2003-11-04). "Fluid and Blood Resuscitation". In Tintinalli JE, Kelen GD, Stapczynski JS (eds.). Emergency Medicine: A Comprehensive Study Guide, Sixth edition. McGraw Hill Professional. p. 227. ISBN 978-0-07-150091-3.
  5. ^ Irita K (March 2011). "Risk and crisis management in intraoperative hemorrhage: Human factors in hemorrhagic critical events". Korean J Anesthesiol. 60 (3): 151–60. doi:10.4097/kjae.2011.60.3.151. PMC 3071477. PMID 21490815.
  6. ^ Webert K, Cook RJ, Sigouin CS, Rebulla P, Heddle NM (November 2006). "The risk of bleeding in thrombocytopenic patients with acute myeloid leukemia". Haematologica. 91 (11): 1530–37. PMID 17043016.
  7. ^ Liberty G, Hyman JH, Eldar-Geva T, Latinsky B, Gal M, Margalioth EJ (December 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.
  8. ^ Wang, Ye; An, Fei-Fei; Chan, Mark; Friedman, Beth; Rodriguez, Erik A; Tsien, Roger Y; Aras, Omer; Ting, Richard (2017-01-05). "18F-positron-emitting/fluorescent labeled erythrocytes allow imaging of internal hemorrhage in a murine intracranial hemorrhage model". Journal of Cerebral Blood Flow & Metabolism. 37 (3): 776–786. doi:10.1177/0271678x16682510. PMC 5363488. PMID 28054494.
  9. ^ "Hemorrhage Origin". dictionary.com. Retrieved 16 July 2015.

External links

External resources
Apoplexy

Apoplexy (from Ancient Greek ἀποπληξία (apoplexia), meaning 'a striking away') is bleeding within internal organs and the accompanying symptoms. For example, ovarian apoplexy is bleeding in the ovaries. The term formerly referred to what is now called a stroke; nowadays, health care professionals typically specify the type of apoplexy, such as cerebral, ovarian and pituitary apoplexy.

Informally or metaphorically, the term apoplexy is associated with being furious, especially as "apoplectic".

Bleeding Cool

Bleeding Cool is an internet news site, focusing on comics, TV, film, and games. Owned by Avatar Press, it was launched by Rich Johnston on 27 March 2009, and has gone through several iterations of design, and many forum changes. Avatar also publishes an associated magazine, Bleeding Cool.

Bleeding Kansas

Bleeding Kansas, Bloody Kansas or the Border War was a series of violent civil confrontations in the United States between 1854 and 1861 which emerged from a political and ideological debate over the legality of slavery in the proposed state of Kansas. The conflict was characterized by years of electoral fraud, raids, assaults, and retributive murders carried out in Kansas and neighboring Missouri by pro-slavery "Border Ruffians" and anti-slavery "Free-Staters".

At the core of the conflict was the question of whether the Kansas Territory would allow or outlaw slavery, and thus enter the Union as a slave state or a free state. The Kansas–Nebraska Act of 1854 called for popular sovereignty, requiring that the decision about slavery be made by the territory's settlers (rather than outsiders) and decided by a popular vote. Existing sectional tensions surrounding slavery quickly found focus in Kansas, with the pro-slavery element arguing that every settler had the right to bring his own property, including slaves, into the territory; anti-slavery "free soil" proponents argued not only that slavery was unethical, but that permitting slavery in Kansas would allow rich slaveholders to control the land to the exclusion of non-slaveholders. Missouri, a slave state since 1821, was populated by a large amount of settlers with Southern sympathies and pro-slavery attitudes, many of whom tried to influence the decision in Kansas. The conflict was fought politically as well as between civilians, where it eventually degenerated into brutal gang violence and paramilitary guerrilla warfare. The term "Bleeding Kansas" was popularized by Horace Greeley's New York Tribune.Bleeding Kansas was demonstrative of the gravity of the era's most pressing social issues, from the matter of slavery to the class conflicts emerging on the American frontier, to state rights. Its severity made national headlines which suggested to the American people that the sectional disputes were unlikely to reach compromise without bloodshed, and it therefore directly led up to the American Civil War, which saw more conflict and bloodshed come to the region. Kansas was admitted to the Union as a free state in January 1861, but partisan violence continued along the Kansas–Missouri border for most of the war. The episode is commemorated with numerous memorials and designated historic sites.

Bleeding Love

"Bleeding Love" is a song performed by British singer Leona Lewis, who released it from her 2007 debut studio album, Spirit. Jointly composed by American singers and songwriters Jesse McCartney and Ryan Tedder, and produced by Tedder, the song is the album's lead single; officially, it was Lewis's official second single, and followed "A Moment Like This". It was released in the United Kingdom and Ireland in October 2007. Debuting at number one on the UK Singles Chart and the Irish Singles Chart, "Bleeding Love" became the best-selling single of 2007 in both countries. After the single's release, it became a major international hit, and was the best-selling single of 2008 worldwide. The single has reached number one in 35 countries, including Japan, Germany and the United States, making it only the second song in history to achieve this feat, Elton John's "Candle in the Wind 1997" being the first. The video first aired on 17 October 2007, and was uploaded to YouTube on the same day, on which it now has over 161 million views."Bleeding Love" has sold more than one million copies in the United Kingdom, and over 4 million digital downloads in the U.S., where it was the best-selling digital song there in 2008. It was named the 17th most successful song in the US from 2000–2009, on the Billboard Hot 100 Songs of the Decade. The song achieved a similar feat in the United Kingdom where it was the best-selling single of 2007, selling 788,000 copies. "Bleeding Love" has charted on the UK Singles Chart in three different years: in 2007 it peaked at number one; 2008 at number 76; and 2009 at number 97. "Bleeding Love" was nominated for Record of the Year and Best Female Pop Vocal Performance at the 51st Grammy Awards. At the 2008 Brit Awards it was nominated for Best British Single. It is Lewis's biggest hit in the US to date, is still her only single to reach the top ten of the Billboard Hot 100 and remains her most successful single worldwide.

Blood in stool

Blood in stool looks different depending on how early it enters the digestive tract—and thus how much digestive action it has been exposed to—and how much there is. The term can refer either to melena, with a black appearance, typically originating from upper gastrointestinal bleeding; or to hematochezia, with a red color, typically originating from lower gastrointestinal bleeding. Evaluation of the blood found in stool depends on its characteristics, in terms of color, quantity and other features, which can point to its source, however, more serious conditions can present with a mixed picture, or with the form of bleeding that is found in another section of the tract. The term "blood in stool" is usually only used to describe visible blood, and not fecal occult blood, which is found only after physical examination and chemical laboratory testing.

In infants, the Apt test can be used to distinguish fetal hemoglobin from maternal blood based on the differences in composition of fetal hemoglobin as compared to the hemoglobin found in adults.

Coagulopathy

Coagulopathy (also called a bleeding disorder) is a condition in which the blood’s ability to coagulate (form clots) is impaired. This condition can cause a tendency toward prolonged or excessive bleeding (bleeding diathesis), which may occur spontaneously or following an injury or medical and dental procedures. Of note, coagulopathies are sometimes erroneously referred to as "clotting disorders"; a clotting disorder is a predisposition to clot formation (thrombus), also known as a hypercoagulable state or thrombophilia.

Exsanguination

Exsanguination is the loss of blood to a degree sufficient to cause death. One does not have to lose all of one's blood to cause death. Depending upon the age, health, and fitness level of the individual, people can die from losing half to two-thirds of their blood; a loss of roughly one-third of the blood volume is considered very serious. Even a single deep cut can warrant suturing and hospitalization, especially if trauma, a vein or artery, or another comorbidity is involved. It is most commonly known as "bleeding to death" or colloquially as "bleeding out". The word itself originates from Latin: ex ("out of") and sanguis ("blood").

Gastrointestinal bleeding

Gastrointestinal bleeding (GI bleed), also known as gastrointestinal hemorrhage, is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool. Small amounts of bleeding over a long time may cause iron-deficiency anemia resulting in feeling tired or heart-related chest pain. Other symptoms may include abdominal pain, shortness of breath, pale skin, or passing out. Sometimes in those with small amounts of bleeding no symptoms may be present.Bleeding is typically divided into two main types: upper gastrointestinal bleeding and lower gastrointestinal bleeding. Causes of upper GI bleeds include: peptic ulcer disease, esophageal varices due to liver cirrhosis and cancer, among others. Causes of lower GI bleeds include: hemorrhoids, cancer, and inflammatory bowel disease among others. Diagnosis typically begins with a medical history and physical examination, along with blood tests. Small amounts of bleeding may be detected by fecal occult blood test. Endoscopy of the lower and upper gastrointestinal tract may locate the area of bleeding. Medical imaging may be useful in cases that are not clear.Initial treatment focuses on resuscitation which may include intravenous fluids and blood transfusions. Often blood transfusions are not recommended unless the hemoglobin is less than 70 or 80 g/L. Treatment with proton pump inhibitors, octreotide, and antibiotics may be considered in certain cases. If other measures are not effective, an esophageal balloon may be attempted in those with presumed esophageal varices. Endoscopy of the esophagus, stomach, and duodenum or endoscopy of the large bowel are generally recommended within 24 hours and may allow treatment as well as diagnosis.An upper GI bleed is more common than lower GI bleed. An upper GI bleed occurs in 50 to 150 per 100,000 adults per year. A lower GI bleed is estimated to occur in 20 to 30 per 100,000 per year. It results in about 300,000 hospital admissions a year in the United States. Risk of death from a GI bleed is between 5% and 30%. Risk of bleeding is more common in males and increases with age.

Haemophilia

Haemophilia is a mostly inherited genetic disorder that impairs the body's ability to make blood clots, a process needed to stop bleeding. This results in people bleeding longer after an injury, easy bruising, and an increased risk of bleeding inside joints or the brain. Those with a mild case of the disease may have symptoms only after an accident or during surgery. Bleeding into a joint can result in permanent damage while bleeding in the brain can result in long term headaches, seizures, or a decreased level of consciousness.There are two main types of haemophilia: haemophilia A, which occurs due to not enough clotting factor VIII, and haemophilia B, which occurs due to not enough clotting factor IX. They are typically inherited from one's parents through an X chromosome with a nonfunctional gene. Rarely a new mutation may occur during early development or haemophilia may develop later in life due to antibodies forming against a clotting factor. Other types include haemophilia C, which occurs due to not enough factor XI, and parahaemophilia, which occurs due to not enough factor V. Acquired haemophilia is associated with cancers, autoimmune disorders, and pregnancy. Diagnosis is by testing the blood for its ability to clot and its levels of clotting factors.Prevention may occur by removing an egg, fertilizing it, and testing the embryo before transferring it to the uterus. Treatment is by replacing the missing blood clotting factors. This may be done on a regular basis or during bleeding episodes. Replacement may take place at home or in hospital. The clotting factors are made either from human blood or by recombinant methods. Up to 20% of people develop antibodies to the clotting factors which makes treatment more difficult. The medication desmopressin may be used in those with mild haemophilia A. Studies of gene therapy are in early human trials.Haemophilia A affects about 1 in 5,000–10,000, while haemophilia B affects about 1 in 40,000, males at birth. As haemophilia A and B are both X-linked recessive disorders, females are rarely severely affected. Some females with a nonfunctional gene on one of the X chromosomes may be mildly symptomatic. Haemophilia C occurs equally in both sexes and is mostly found in Ashkenazi Jews. In the 1800s haemophilia B was common within the royal families of Europe. The difference between haemophilia A and B was determined in 1952. The word is from the Greek haima αἷμα meaning blood and philia φιλία meaning love.

Heavy menstrual bleeding

Heavy menstrual bleeding, previously known as menorrhagia, is a menstrual period with excessively heavy flow and falls under the larger category of abnormal uterine bleeding (AUB).Abnormal uterine bleeding can be caused by structural abnormalities in the reproductive tract, anovulation, bleeding disorders, hormone issues (such as hypothyroidism) or cancer of the reproductive tract. Initial evaluation aims at figuring out pregnancy status, menopausal status, and the source of bleeding.

Treatment depends on the cause, severity, and interference with quality of life. Initial treatment often involve contraceptive pills. Surgery can be an effective second line treatment for those women whose symptoms are not well-controlled. Approximately 53 in 1000 women are affected by AUB.

Internal bleeding

Internal bleeding (also called internal hemorrhage) is a loss of blood from a blood vessel that collects inside the body. Internal bleeding is usually not visible from the outside. It is a serious medical emergency but the extent of severity depends on bleeding rate and location of the bleeding (e.g. head, torso, extremities). Severe internal bleeding into the chest, abdomen, retroperitoneal space, pelvis, and thighs can cause hemorrhagic shock or death if proper medical treatment is not received quickly. Internal bleeding is a medical emergency and should be treated immediately by medical professionals.

Intracerebral hemorrhage

Intracerebral hemorrhage (ICH), also known as cerebral bleed, is a type of intracranial bleed that occurs within the brain tissue or ventricles. Symptoms can include headache, one-sided weakness, vomiting, seizures, decreased level of consciousness, and neck stiffness. Often symptoms get worse over time. Fever is also common. In many cases bleeding is present in both the brain tissue and the ventricles.Causes include brain trauma, aneurysms, arteriovenous malformations, and brain tumors. The largest risk factors for spontaneous bleeding are high blood pressure and amyloidosis. Other risk factors include alcoholism, low cholesterol, blood thinners, and cocaine use. Diagnosis is typically by CT scan. Other conditions that may present similarly include ischemic stroke.Treatment should typically be carried out in an intensive care unit. Guidelines recommended decreasing the blood pressure to a systolic of 140 mmHg. Blood thinners should be reversed if possible and blood sugar kept in the normal range. Surgery to place a ventricular drain may be used to treat hydrocephalus but corticosteroids should not be used. Surgery to remove the blood is useful in certain cases.Cerebral bleeding affects about 2.5 per 10,000 people each year. It occurs more often in males and older people. About 44% of those affected die within a month. A good outcome occurs in about 20% of those affected. Strokes were first divided into their two major types, bleeding and insufficient blood flow, in 1823.

Menstruation

Menstruation, also known as a period or monthly, is the regular discharge of blood and mucosal tissue (known as menses) from the inner lining of the uterus through the vagina. The first period usually begins between twelve and fifteen years of age, a point in time known as menarche. However, periods may occasionally start as young as eight years old and still be considered normal. The average age of the first period is generally later in the developing world, and earlier in the developed world. The typical length of time between the first day of one period and the first day of the next is 21 to 45 days in young women, and 21 to 31 days in adults (an average of 28 days). Bleeding usually lasts around 2 to 7 days. Menstruation stops occurring after menopause, which usually occurs between 45 and 55 years of age. Periods also stop during pregnancy and typically do not resume during the initial months of breastfeeding.Up to 80% of women report having some symptoms prior to menstruation. Common signs and symptoms include acne, tender breasts, bloating, feeling tired, irritability, and mood changes. These may interfere with normal life, therefore qualifying as premenstrual syndrome, in 20 to 30% of women. In 3 to 8%, symptoms are severe.A lack of periods, known as amenorrhea, is when periods do not occur by age 15 or have not occurred in 90 days. Other problems with the menstrual cycle include painful periods and abnormal bleeding such as bleeding between periods or heavy bleeding. Menstruation in other animals occur in primates (apes and monkeys).The menstrual cycle occurs due to the rise and fall of hormones. This cycle results in the thickening of the lining of the uterus, and the growth of an egg, (which is required for pregnancy). The egg is released from an ovary around day fourteen in the cycle; the thickened lining of the uterus provides nutrients to an embryo after implantation. If pregnancy does not occur, the lining is released in what is known as menstruation.

Nosebleed

A nosebleed, also known as epistaxis ( EP-ih-STAK-sis), is the common occurrence of bleeding from the nose. It is usually noticed when blood drains out through the nostrils.

There are two types: anterior (the most common), and posterior (less common, more likely to require medical attention). Sometimes in more severe cases, the blood can come up the nasolacrimal duct and out from the eye. Fresh blood and clotted blood can also flow down into the stomach and cause nausea and vomiting.Although the sight of large amounts of blood can be alarming and may warrant medical attention, nosebleeds are rarely fatal, accounting for only 4 of the 2.4 million deaths in the U.S. in 1999. About 60% of people have a nosebleed at some point in their life. About 10% of nosebleeds are serious. Nosebleeds appear to have a bimodal distribution, most commonly affecting those younger than 10 and older than 50.

Peptic ulcer disease

Peptic ulcer disease (PUD) is a break in the inner lining of the stomach, first part of the small intestine or sometimes the lower esophagus. An ulcer in the stomach is called a gastric ulcer, while that in the first part of the intestines is a duodenal ulcer. The most common symptoms of a duodenal ulcer are waking at night with upper abdominal pain or upper abdominal pain that improves with eating. With a gastric ulcer the pain may worsen with eating. The pain is often described as a burning or dull ache. Other symptoms include belching, vomiting, weight loss, or poor appetite. About a third of older people have no symptoms. Complications may include bleeding, perforation and blockage of the stomach. Bleeding occurs in as many as 15% of people.Common causes include the bacteria Helicobacter pylori and non-steroidal anti-inflammatory drugs (NSAIDs). Other less common causes include tobacco smoking, stress due to serious illness, Behcet disease, Zollinger-Ellison syndrome, Crohn disease and liver cirrhosis, among others. Older people are more sensitive to the ulcer-causing effects of NSAIDs. The diagnosis is typically suspected due to the presenting symptoms with confirmation by either endoscopy or barium swallow. H. pylori can be diagnosed by testing the blood for antibodies, a urea breath test, testing the stool for signs of the bacteria, or a biopsy of the stomach. Other conditions that produce similar symptoms include stomach cancer, coronary heart disease, and inflammation of the stomach lining or gallbladder inflammation.Diet does not play an important role in either causing or preventing ulcers. Treatment includes stopping smoking, stopping NSAIDs, stopping alcohol and giving medications to decrease stomach acid. The medication used to decrease acid is usually either a proton pump inhibitor (PPI) or an H2 blocker with four weeks of treatment initially recommended. Ulcers due to H. pylori are treated with a combination of medications such as amoxicillin, clarithromycin and a PPI. Antibiotic resistance is increasing and thus treatment may not always be effective. Bleeding ulcers may be treated by endoscopy, with open surgery typically only used in cases in which it is not successful.Peptic ulcers are present in around 4% of the population. New ulcers were found in around 87.4 million people worldwide during 2015. About 10% of people develop a peptic ulcer at some point in their life. They resulted in 267,500 deaths in 2015 down from 327,000 deaths in 1990. The first description of a perforated peptic ulcer was in 1670 in Princess Henrietta of England. H. pylori was first identified as causing peptic ulcers by Barry Marshall and Robin Warren in the late 20th century, a discovery for which they received the Nobel Prize in 2005.

Postpartum bleeding

Postpartum bleeding or postpartum hemorrhage (PPH) is often defined as the loss of more than 500 ml or 1,000 ml of blood within the first 24 hours following childbirth. Some have added the requirement that there also be signs or symptoms of low blood volume for the condition to exist. Signs and symptoms may initially include: an increased heart rate, feeling faint upon standing, and an increased breath rate. As more blood is lost, the woman may feel cold, blood pressure may drop, and she may become restless or unconscious. The condition can occur up to six weeks following delivery.The most common cause is poor contraction of the uterus following childbirth. Not all of the placenta being delivered, a tear of the uterus, or poor blood clotting are other possible causes. It occurs more commonly in those who: already have a low amount of red blood, are Asian, with bigger or more than one baby, are obese or are older than 40 years of age. It also occurs more commonly following caesarean sections, those in whom medications are used to start labor, those requiring the use of a vacuum or forceps, and those who have an episiotomy.Prevention involves decreasing known risk factors including procedures associated with the condition, if possible, and giving the medication oxytocin to stimulate the uterus to contract shortly after the baby is born. Misoprostol may be used instead of oxytocin in resource poor settings. Treatments may include: intravenous fluids, blood transfusions, and the medication ergotamine to cause further uterine contraction. Efforts to compress the uterus using the hands may be effective if other treatments do not work. The aorta may also be compressed by pressing on the abdomen. The World Health Organization has recommended non-pneumatic anti-shock garment to help until other measures such as surgery can be carried out. A 2017 study found that tranexamic acid decreased a woman's risk of death.In the developing world about 1.2% of deliveries are associated with PPH and when PPH occurred about 3% of women died. Globally it occurs about 8.7 million times and results in 44,000 to 86,000 deaths per year making it the leading cause of death during pregnancy. About 0.4 women per 100,000 deliveries die from PPH in the United Kingdom while about 150 women per 100,000 deliveries die in sub-Saharan Africa. Rates of death have decreased substantially since at least the late 1800s in the United Kingdom.

Subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain. Symptoms may include a severe headache of rapid onset, vomiting, decreased level of consciousness, fever, and sometimes seizures. Neck stiffness or neck pain are also relatively common. In about a quarter of people a small bleed with resolving symptoms occurs within a month of a larger bleed.SAH may occur as a result of a head injury or spontaneously, usually from a ruptured cerebral aneurysm. Risk factors for spontaneous cases included high blood pressure, smoking, family history, alcoholism, and cocaine use. Generally, the diagnosis can be determined by a CT scan of the head if done within six hours of symptom onset. Occasionally a lumbar puncture is also required. After confirmation further tests are usually performed to determine the underlying cause.Treatment is by prompt neurosurgery or radiologically guided interventions. Medications such as labetalol may be required to lower the blood pressure until repair can occur. Efforts to treat fevers are also recommended. Nimodipine, a calcium channel blocker, is frequently used to prevent vasospasm. Routine use medications to prevent further seizures is of unclear benefit. Nearly half of people with a SAH due to an underlying aneurysm die within 30 days and about a third who survive have ongoing problems. 10–15 percent die before reaching a hospital.Spontaneous SAH occurs in about one per 10,000 people per year. Females are more commonly affected than males. While it becomes more common with age, about 50% of people present under 55 years old. It is a form of stroke and comprises about 5 percent of all strokes. Surgery for aneurysms was introduced in the 1930s. Since the 1990s many aneurysms are treated by a less invasive procedure called endovascular coiling, which is carried out through a large blood vessel.

Upper gastrointestinal bleeding

Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.

The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.

Upper gastrointestinal bleeding affects around 50 to 150 people per 100,000 annually. Depending on its severity, it carries an estimated mortality risk of 11%.

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