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PubMed1983

Bleeding in cirrhotic patients: a precipitating factor due to intravascular coagulation or to hepatic failure?

In 24 cirrhotic patients at different stages of hepatic failure, factor VIII:C (F VIII:C), factor VIIIR:AG (F VIIIR:AG), factor VIII AG/C ratio (F VIII AG/C), and serum fibrin-fibrinogen degradation products (FDP) were investigated. In 11 of the 24 patients, several instances of gastrointestinal bleeding due to esophageal varices rupture were documented and 5 patients died of unarrestable bleeding. In our study, we evaluated whether the cause of bleeding was the development of intravascular coagulation or the severity of hepatic failure. A statistically significant difference between F VIII:C, F VIIIR:AG/C ratio, and serum FDP was found in bleeding in comparison with non-bleeding patients. An inverse correlation between the F VIII:C plasma level and serum FDP as well as a direct correlation between F VIII AG/C ratio and serum FDP in the group of bleeding patients were also found. These data seem to suggest a hypercoagulable state which was more significant in the 5 patients who died owing to bleeding. Furthermore, only 1 of these patients had severe hepatic failure. From this study it appears that, in cirrhotic patients, bleeding is related more to the appearance of disseminated intravascular coagulation, as a consequence of both hemodynamic and endothelial changes, than to the degree of hepatic failure itself.

Adult↗
PubMed1996

Factors that predict the bleeding risk of cerebral arteriovenous malformations.

BACKGROUND AND PURPOSE: Arteriovenous malformations (AVMs) have an overall 2% to 4% annual risk of hemorrhage. The purpose of this study was to determine whether specific clinical and radiographic factors predispose AVMs to bleed and to predict the bleeding risk for individual AVM patients. METHODS: We reviewed the clinical histories and cerebral angiograms of 315 AVM patients who underwent stereotactic radiosurgery at our center. One half of the patient data (analysis cohort) was used to determine risk factors for bleeding and to construct AVM hemorrhage risk groups. These risk groups were then tested with the second half of the patient data (test cohort). RESULTS: The mean AVM volume was 4.0 +/- 3.4 mL (approximate maximum diameter of 2 cm). One hundred ninety-six initial hemorrhages occurred in 10,348 patient-years for an annual initial bleed rate of 1.89%; 44 of these 196 patients had a repeat bleed in 591 patient-years for an annual rebleed rate of 7.45%. The overall crude annual hemorrhage rate was 2.40%. Multivariate analysis revealed three factors associated with hemorrhage: history of a prior bleed (relative risk [RR], 9.09; 95% confidence interval [CI], 5.44 to 15.19; P < .001), a single draining vein (RR, 1.66; 95% CI, 1.13 to 2.38; P < .01), and a diffuse AVM morphology (RR, 1.64; 95% CI, 1.12 to 2.46; P < .01). Four AVM hemorrhage risk groups were constructed on the basis of the significant factors. The annual rate of bleeding was 0.99% for low-risk AVMs, 2.22% for intermediate-low-risk AVMs, 3.72% for intermediate-high-risk AVMs, and 8.94% for high-risk AVMs. CONCLUSIONS: Analysis of a large group of AVM patients who underwent stereotactic radiosurgery demonstrated that small AVMs have an annual hemorrhage risk similar to that of the general AVM population. AVM patients have a wide variability of bleeding risk that can be predicted from their clinical presentation and the angiographic characteristics of the AVM. The management of AVM patients should be based not only on the morbidity of the proposed treatment but also those factors that predispose individual patients to either a low or high hemorrhage risk.

Adult↗
PubMed1979

Shortening of the bleeding time in rabbits by hydrocortisone caused by inhibition of prostacyclin generation by the vessel wall.

The effect of hydrocortisone on thrombocytopenic bleeding has been studied in rabbits using a jugular vein bleeding-time technique and a microvascular bleeding-time technique. An inverse relationship was found between the bleeding time and platelet count with both techniques in rabbits made thrombocytopenic by either X-irradiation or injection of heterologous platelet antiserum. Hydrocortisone shortened both bleeding times in thrombocytopenic animals when given in single large doses intravenously (25-100 mg/kg), in daily doses (6 mg/kg) intramuscularly, and shortened the jugular bleeding time when applied to the outside of the jugular vein or instilled intraluminally into the vein. This effect was also noted in normal animals. The effect on thrombocytopenic bleeding was dose related. When given daily, the effect was greater when hydrocortisone was given for 10 d than for 5 d. Both indomethacin and tranylcypromine also reduced the jugular vein bleeding time when instilled intraluminally into the jugular vein, whereas exogenously provided arachidonic acid reversed the effect of hydrocortisone but did not reverse the effect of indomethacin or tranylcypromine. Exogenously provided linoleic acid did not have any effect. Perfusion of the vessel segment with prostacyclin (PGI(2)) reversed the effect of intraluminally administered hydrocortisone, indomethacin, and tranylcypromine. Similarly, hydrocortisone, indomethacin, and tranylcypromine all reduced the rate of loss of fluid from a standard wound in isolated vessels emptied of blood and perfused with saline under constant pressure. PGI(2) reversed the action of these three agents, however, arachidonic acid reversed only the effect of hydrocortisone and did not reverse the effect of indomethacin and tranylcypromine. The generation of PGI(2)-like material and 6-keto-prostaglandinF(1) alpha from jugular vein strips was prevented by prior exposure of the animals or vessel wall to hydrocortisone. These results are compatible with the hypothesis that the vessel wall releases smooth muscle-relaxing prostaglandins when injured and that inhibition of prostaglandin formation by hydrocortisone enhances hemostasis by allowing vasoconstriction to be maintained.

Animals↗
PubMed2005

Diagnosis and management of mild bleeding disorders.

Mild bleeding disorders are a common reason for a referral to a hematologist and these conditions can be challenging to evaluate. Recent research has highlighted that some bleeding symptoms are quite common in the general population and that there is clinical variability in symptom expression among individuals with defined bleeding problems. Moreover, bleeding risks for many bleeding disorders are unknown. This article reviews symptoms and problems that can be considered suspicious of a mild form of bleeding disorder and the diagnostic investigations useful to evaluate these problems. A stepwise approach is presented for the diagnostic evaluation, to allow detection of common and rare coagulation and fibrinolytic defects, and adequate assessments of potential von Willebrand factor and platelet problems. Some common problems in the diagnosis and management of mild bleeding problems are reviewed, including the common failure to establish a diagnosis with testing. An approach is proposed for translation of knowledge to patients who are challenged by mild bleeding problems.

Blood Coagulation Disorders↗
PubMed2006

Bleeding disorders in premenopausal women: (another) public health crisis for hematology?

Premenopausal women with bleeding disorders represent a major public health problem. Estimates suggest up to 20% of women with menorrhagia have an underlying bleeding disorder (corresponding to a prevalence of 1.5-4 million American women). Von Willebrand disease (VWD) is the most common bleeding disorder among women with menorrhagia, affecting up to 20% of such patients. Besides menorrhagia, important consequences of bleeding disorders in premenopausal women include iron deficiency anemia, miscarriage, postpartum bleeding, uterine bleeding and hysterectomy. These patients face many obstacles in achieving optimum care. Recognition is difficult as women may consider their symptoms "normal" and come to attention only after serious bleeding events. Symptoms of VWD may also overlap with benign conditions, primary providers may not suspect the diagnosis, and convenient hematologic input may be unavailable. Diagnosis is difficult as there is no single definitive test for VWD, and test results are variable, often being affected by extragenic factors, including stress, contraceptives, hormones, and pregnancy. Hemostatic treatment is limited by DDAVP tachyphylaxis, the lack of recombinant VWD concentrates, and the ineffectiveness of hormonal therapy, leading to unnecessary procedures and early hysterectomy. Finally, significant controversy exists regarding classification of type 1 VWD as a disease: given the overlap in symptoms and laboratory assays within the normal population, evaluation for those with VWD might be seen as identification of potential bleeding risk rather than detection of a disease. This symposium seeks to explore these issues in greater detail from the combined perspectives of the obstetrician-gynecologist and the hematologist to promote a better public health approach to this problem.

Adult↗
PubMed1993

Subsequent bleeding from ruptured intracranial aneurysms treated by wrapping or coating: a review of the long-term results in 47 cases.

Forty-seven patients, who underwent surgery over a 34-year period by the wrapping or coating of ruptured intracranial aneurysms, have been retrospectively evaluated. The following materials were used in the surgical procedures: muscle with gelatin sponge (7 cases), gauze (2 cases), oxidized cellulose with Biobond (28 cases), Histoacryl with gauze or fascia (10 cases). The patients were monitored for up to 37 years (mean, 13.7 +/- 8.2 yr). One or more subsequent bleedings occurred in eight patients (17%). Three patients had additional bleeding and died in the early postoperative phase (within 1 mo after surgery). In five patients, the subsequent bleeding occurred between 1 and 15 years postoperatively, with two fatalities. One patient experienced two recurrences. Therefore, the mortality rate for postoperative bleedings was 10.6% (five patients) in the whole series, and the incidence of early (within 1 mo after surgery) fatal bleedings was 6.4%. After the first month from the initial hemorrhage, the global risk of subsequent bleeding was 0.93%/yr. Among the nine patients whose aneurysms were wrapped with muscle, gelatin sponge, or gauze, four additional bleedings occurred, whereas four relapses were observed among the 38 cases treated by employing bioadhesive agents (P < 0.04; Fisher's exact test). The rate of further bleeding was higher (25%) in patients undergoing surgery in the premicrosurgical era compared with that (8.7%) recorded in patients treated by microsurgery (difference statistically not significant).

Adolescent↗
PubMed2001

Octreotide for acute variceal bleeding.

OBJECTIVE: To review the use o f octreotide for acute variceal bleeding. DATA SOURCES: Articles were obtained through computerized searches involving MEDLINE (from 1997 to October 2000). Additionally, several textbooks containing information on the diagnosis and management of acute variceal bleeding were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references. STUDY SELECTION: All randomized studies and pharmacoeconomic evaluations that used octreotide therapy for acute variceal bleeding were considered. Randomized controlled trials and meta-analyses involving other therapies for treating variceal bleeding were also reviewed for possible inclusion. DATA EXTRACTION: The primary outcomes extracted from the literature were persistent or recurrent bleeding, need for endoscopic intervention or balloon tamponade, and mortality. DATA SYNTHESIS: Although both endoscopic therapies and medications are used to control bleeding and rebleeding episodes, the endoscopic approach has the additional goal of obliterating the varix. Since rebleeding episodes are common as long as the varix is present, endoscopic and medication therapies cannot be considered interchangeable based on bleeding control alone. However, octreotide by continuous intravenous infusion has demonstrated effectiveness in reducing blood loss and transfusion requirements as both an initial intervention (until definitive sclerotherapy can be performed) or as adjunctive therapy to endoscopic measures. Octreotide can be started quickly, has a relatively rapid onset of action, and does not require someone with endoscopy training to initiate. Additionally, octreotide is relatively free of significant adverse effects. CONCLUSIONS: While additional investigations are needed, particularly in the area of pharmacoeconomics, there is substantial evidence that octreotide is an efficacious therapy with relatively few adverse effects when used in the management of acute variceal bleeding.

Esophageal and Gastric Varices↗
PubMed2004

Dosing practices and risk factors for bleeding in patients receiving enoxaparin for the treatment of an acute coronary syndrome.

OBJECTIVES: To describe dosing practices and to identify risk factors for bleeding in patients with an acute coronary syndrome (ACS) who received treatment with enoxaparin. DESIGN: Retrospective chart review. SETTING: Coronary care unit of a tertiary-care teaching hospital. PATIENTS: Patients with a discharge diagnosis of an ACS who received at least one dose of enoxaparin, 1 mg/kg, were eligible for this study. Enoxaparin dosing practices, factors that might influence the safety of enoxaparin administration, and bleeding events were documented. Multivariable regression analysis was used to identify independent predictors of bleeding in this clinical setting. RESULTS: Of 208 patients with an ACS who received enoxaparin, 48 patients (23%) received a dose that was > 10% or < 10% of the recommended 1 mg/kg dose, 18 patients (9%) did not have body weight documentation to guide enoxaparin dosing, and 17 patients (8%) had significant renal impairment (serum creatinine > 150 micromol/L), with the potential for bioaccumulation of enoxaparin. There were 35 bleeding events (17%), of which 8 events (4%) were major. Risk factors for any bleeding (major or minor) were increasing patient age (odds ratio [OR], 1.57; 95% confidence interval [CI], 1.13 to 2.20), coadministered nonsteroidal anti-inflammatory or antiplatelet drug therapy (OR, 2.38; 95% CI, 1.06 to 5.38), and number of enoxaparin doses (OR, 2.15; 95% CI, 1.25 to 3.68). Risk factors for major bleeding were increasing patient age (OR, 2.56; 95% CI, 1.05 to 6.28) and coadministered clopidogrel (OR, 7.70; 95% CI, 1.16 to 51.9). CONCLUSION: In this clinical practice assessment of patients with an ACS, the use of enoxaparin was suboptimal, with the potential to increase bleeding complications. Coadministered clopidogrel, other drugs that affect hemostasis, and increasing age conferred an increased bleeding risk.

Acute Disease↗
PubMed1987

Left-to-right shunts in control of bleeding following surgery for aneurysms of the ascending aorta.

Surgical repair of complex thoracic aneurysms requiring aortic valve replacement and coronary revascularization is occasionally complicated by significant bleeding despite the experience of the surgeon. While bleeding from the mediastinal tissues and the anterior suture line is usually easily controlled, posterior bleeding may require dismantling the repair and a second bypass run. The synergism of a second bypass run and continued bleeding may result in increased mortality and/or morbidity. We recently encountered bleeding in a patient who developed ventricular dysfunction after bypass and opted to interpose a Gore-tex graft between the aneurysm wall and the right atrium with immediate hemostasis and a benign course. Subsequently we used four different shunts successfully in 9 of 33 patients. The average bleeding rate 30 minutes after protamine was 221 +/- 60 ml/minute with a range of 190 to 350 ml/minute. The initial two hour chest tube drainage averaged 880 +/- 285 ml with a range of 490 to 1300 ml. There were no re-explorations for bleeding. The shunt in the first patient has remained open without cardiac decompensation. The last patient developed heart failure and required elective repair of a leak at the descending end of an arch replacement. Our experience suggests that these shunts can be effective, particularly if posterior suture line bleeding is encountered.

Aged↗
PubMed2006

Rectal bleeding in infancy: clinical, allergological, and microbiological examination.

OBJECTIVE: Rectal bleeding is an alarming symptom and requires additional investigation. In infants it has been explained mainly by hypersensitivity. In addition to dietary antigens, intraluminal microbial agents challenge the immature gut mucosa. Although controlled in the mature gut, these antigens may induce inflammation in the developing gastrointestinal tract. The objectives of this study were to evaluate prospectively the clinical course of rectal bleeding and evaluate the impact of cow's milk allergy and aberrant gut microbiota on the condition. Because withdrawal of cow's milk antigens from the infants' diet is used as a first treatment without evidence of its efficacy, we also aimed to asses the effect of a cow's milk-elimination diet on the duration of rectal bleeding. METHODS: The study involved 40 consecutive infants (mean age: 2.7 months) with visible rectal bleeding during a 2-year period at the Tampere University Hospital Department of Pediatrics. Most of the infants (68%) were fully breastfed. At enrollment the infants were randomly allocated to receive a cow's milk-elimination diet (n = 19) or continue their previous diet (n = 21) for 1 month. Findings of colonoscopy, fecal bacterial culture, fluorescence in situ hybridization of selected gut genera, specific detection of fecal enteroviruses, rotaviruses, and adenoviruses, fecal electron microscopy for viruses, and mucosal electron microscopy for viruses were assessed. During each visit the severity of atopic eczema, if any, was assessed according to the SCORAD method. In evaluating the extent of sensitization, serum total immunoglobulin E (IgE) and specific IgE and skin-prick tests for cow's milk, egg, and wheat were studied. Cow's milk allergy was diagnosed by elimination and provocation testing. Five patients were hospitalized; all others were treated on an outpatient basis. The follow-up visits were scheduled 1 month later and at the age of 1 year. Sixty-four healthy reference infants were selected as controls according to the following criteria: age and timing of fecal sampling being identical to within 1 month. RESULTS: Altogether, 32 (80%) infants manifested bloody stools during follow-up (mean [range]: 2.1 [1-15] per day). The mean number of days with rectal bleeding on follow-up was 6. Typically, bloody stools occurred irregularly, for which reason the mean time to the last occurrence of rectal bleeding was 24 (range: 1-85) days from admission. Atopic eczema at presentation or during follow-up was diagnosed in 38% of the infants. Increased specific IgE concentrations or a positive skin-prick test were uncommon. The growth of the infants was normal on admission and during follow-up. Colonoscopy revealed typically focal mucosal erythema and aphthous ulcerations. The mucosa appeared normal in less than half of the patients. No anorectal fissures or colonic polyps were found. Light microscopy revealed that the overall architecture of the mucosa was well maintained. Acute inflammation or postinflammatory state and focal infiltration of eosinophils in the lamina propria were the most common abnormalities. A cow's milk-elimination diet did not affect the duration of rectal bleeding. Cow's milk allergy was diagnosed in 7 (18%) patients. Virus-particle aggregates were found in the microvillus layer of the colon epithelium in 8 cases. The surface epithelium of the virus-positive colon biopsy specimens regularly showed degenerative changes in the microvillus layer and epithelial cells. Electron microscopy study of the colon biopsies disclosed virus particles (30 nm in diameter) on the surface of epithelial cells. Virus particles or RNA were present in feces in only a minority of the patients. All fecal cultures were negative for Salmonella, Shigella, and Yersinia. Campylobacter jejuni was found in the feces of 1 patient, and fecal cultures were positive for Clostridium difficile in 4 patients, Staphylococcus aureus in 8 patients, and yeast in 2 patients. Fluorescence in situ hybridization revealed that at the time of admission the total numbers of bacteria and the numbers of bifidobacteria and lactobacilli in feces were lower in the patients compared with controls. The fecal concentrations of microbes characterized in this study (Bacteroides, bifidobacteria, Clostridium, lactobacilli, and enterococci) did not differ significantly between the time of admission and the second visit in the patients or controls. At the age of 1 year, 7 patients still suffered from cow's milk allergy, 5 of whom also suffered from multiple food allergies. Atopic eczema and histopathologically confirmed inflammation of the colonic mucosa at presentation were associated with persistence of cow's milk allergy at the age of 1 year. No patients exhibited gastrointestinal complaints or visible blood in stools. CONCLUSIONS: Rectal bleeding in infants is generally a benign and self-limiting disorder. Bloody stools occurred irregularly for only a few days during the following months. As in a previous report, most infants were exclusively breastfed. In the majority of the patients the cause of the condition remains unknown. An association with viruses can be seen in some patients. The microbes that commonly lead to bloody diarrhea in older children and adults, Salmonella, Shigella, and Yersinia, were absent in the present material. The low bifidobacterial numbers in fecal samples may indicate a significant aberrance that may provide a target for probiotic intervention to normalize gut microbiota. The gut microbiota overall seemed stable, because the numbers of major groups of microbiota tested did not change significantly between the time of admission and after 1 month. Cow's milk allergy among these patients is more uncommon than previously believed. Cow's milk challenge is thus essential in infants who become symptom-free during a cow's milk-free diet to reduce the number of false-positive cow's milk-allergy diagnoses.

Animals↗
PubMed2004

Effect of age on international normalized ratio at the time of major bleeding in patients treated with warfarin.

STUDY OBJECTIVES: Because the risk of major bleeding associated with warfarin increases with increasing international normalized ratio (INR) as well as with advanced age, we evaluated the association between age and INR in patients with major bleeding events related to anticoagulation with warfarin. DESIGN: Retrospective record review. SETTING: Two university-affiliated anticoagulation clinics. PATIENTS: Sixty-six patients (mean age 61.2 yrs, range 21-90 yrs) receiving warfarin therapy who experienced major bleeding, defined as bleeding requiring hospitalization, during a 20-month index period. MEASUREMENTS AND MAIN RESULTS: In patients aged 65 years or older, the mean INR at the time of a major bleeding event was significantly lower than that in patients younger than 65 years (INR 3.1 vs 4.2, respectively; p=0.01). For every 1-year increase in age, mean INR at the time of a major bleeding event decreased by 0.03 (p=0.02). CONCLUSION: Patients aged 65 years or older experience warfarin-related major bleeding events at a mean INR 1.1 units lower (95% confidence interval -1.9 to -0.27) than patients younger than 65 years. Older patients may require more aggressive management of overanticoagulation to minimize the risk of major bleeding.

Adult↗
PubMed1981

The gingival bleeding time index.

Recent studies have supported an emphasis on gingival bleeding indices for detection of inflammation. The purposes of the present study were: (1) to evaluate the relationships between the time necessary for stimulated gingival bleeding to occur and both gingival fluid flow and Löe's gingival index, and (2) to develop a clinical index based on gingival bleeding time. In the first part of the study, the elapsed time for gingival bleeding to first occur after sulcular stimulation was correlated with the gingival index and fluid flow on 150 gingival units. A high correlation was found between bleeding time with both the gingival index and exudate flow. A bleeding time index based on a scattergram of the data obtained in part I of the study was then formulated and evaluated in a similar fashion on an additional 172 gingival units. Results indicate a high correlation between the bleeding time index and the other indices. It is concluded that the bleeding time index may be used by itself as an accurate and objective clinical tool to evaluate gingival inflammation.

Gingival Crevicular Fluid↗
PubMed1988

Associations between bleeding and visual signs of interdental gingival inflammation.

Interdental gingival tissues are designated inflamed on the basis of their color and bleeding after stimulation. Gingival bleeding was previously shown in histological studies to indicate the presence of inflammatory lesions. The present study was undertaken to determine associations between bleeding and visual signs of interdental gingival inflammation. Each interdental site in 82 males, aged 18 to 30, was evaluated for the presence or absence of visual signs of inflammation. The interdental sites on one side of the mouth were evaluated for bleeding tendency using the Papilla Bleeding Index (PBI), while the other half was evaluated using the Eastman Interdental Bleeding Index (EIBI). The percentage of inflamed areas detected with the EIBI and visual method was similar and significantly higher than with the PBI. When the visually noninflamed sites were examined, 38.5% of these areas bled, indicating that interdental inflammatory lesions existed in the absence of visual signs of inflammation. Of the sites that bled but were visually noninflamed, 33.1% were detected using the PBI, while 66.9% were detected using the EIBI. The Eastman Interdental Bleeding Index was a more reliable clinical indicator for detecting interdental inflammatory lesions than the Papilla Bleeding Index.

Adolescent↗
PubMed1999

Gingival recession, gingival bleeding, and dental calculus in adults 30 years of age and older in the United States, 1988-1994.

BACKGROUND: The aim of this study was to assess the prevalence and extent of gingival recession, gingival bleeding, and dental calculus in United States adults, using data collected in the third National Health and Nutrition Examination Survey (NHANES III). METHODS: The study group consisted of 9,689 persons 30 to 90 years of age obtained by a stratified, multi-stage probability sampling method in 1988 to 1994. The weighted sample is representative of U.S. adults 30 years or older and represents approximately 105.8 million civilian, non-institutionalized Americans. Gingival recession, gingival bleeding, and dental calculus were assessed at the mesio-buccal and mid-buccal surfaces in 2 randomly selected quadrants, one maxillary and one mandibular. Data analysis accounted for the complex sampling design used. RESULTS: We estimate that 23.8 million persons have one or more tooth surfaces with > or = 3 mm gingival recession; 53.2 million have gingival bleeding; 97.1 million have calculus; and 58.3 million have subgingival calculus; and the corresponding percentages are 22.5%, 50.3%, 91.8%, and 55.1% of persons, respectively. The prevalence, extent, and severity of gingival recession increased with age, as did the prevalence of subgingival calculus and the extent of teeth with calculus and gingival bleeding. Males had significantly more gingival recession, gingival bleeding, subgingival calculus, and more teeth with total calculus than females. Of the 3 race/ethnic groups studied, non-Hispanic blacks had the highest prevalence and extent of gingival recession and dental calculus, whereas Mexican Americans had the highest prevalence and extent of gingival bleeding. Mexican Americans had similar prevalence and extent of gingival recession compared with non-Hispanic whites. Gingival recession was much more prevalent and also more severe at the buccal than the mesial surfaces of teeth. Gingival bleeding also was more prevalent at the buccal than mesial surfaces, whereas calculus was most often present at the mesial than buccal surfaces. CONCLUSIONS: Dental calculus, gingival bleeding, and gingival recession are common in the U.S. adult population. In addition to their unfavorable effect on esthetics and self-esteem, these conditions also are associated with destructive periodontal diseases and root caries. Appropriate measures to prevent or control these conditions are desirable, and this may also be effective in improving the oral health of the U.S. adult population.

Adult↗
PubMed2005

Postbiopsy splenic bleeding in a dog model: comparison of cauterization, embolization, and plugging of the needle tract.

OBJECTIVE: The purpose of our study was to compare radiofrequency cauterization, embolization using an absorbable gelatin sponge, and a Histoacryl-Lipiodol mixture plugging as postbiopsy bleeding reduction methods after splenic core needle biopsy in a dog model. MATERIALS AND METHODS: Eleven mongrel dogs were randomly separated into nonheparinized (n = 5) and heparinized (n = 6) groups. Eight splenic biopsies per animal were performed using an 18-gauge automated core biopsy needle: two as controls, two ablated by radiofrequency, two embolized using an absorbable gelatin sponge, and two plugged using a Histoacryl-Lipiodol mixture. Procedure times and postbiopsy bleeding amounts were assessed. Statistically significant differences were determined by repeated measures analysis of variance; the Tukey-Kramer test for multiple comparisons was used for post hoc comparisons. Three-day follow-up CT scans were obtained to check for procedure-related complications or delayed bleeding. RESULTS: The postbiopsy bleeding reduction groups showed significantly less blood loss than the control group for both the nonheparinized (p < 0.0001) and heparinized groups (p < 0.0001). In the heparinized group, both radiofrequency cauterization (p < 0.01) and gelatin sponge embolization (p < 0.05) significantly reduced bleeding compared with Histoacryl-Lipiodol mixture plugging. Gelatin sponge embolization was the longest procedure (p < 0.001). On follow-up CT, no delayed bleeding was observed. However, multiple Histoacryl-Lipiodol emboli were observed in the splenic and portal veins in all the dogs we treated. CONCLUSION: Radiofrequency cauterization was found to be the most useful postbiopsy bleeding reduction method in terms of the amount of bleeding and the procedure time.

Analysis of Variance↗
PubMed1981

Localization of gastrointestinal bleeding: superiority of 99mTc sulfur colloid compared with angiography.

Preliminary experience with technetium-99m sulfur colloid scintigraphy in 43 patients with lower gastrointestinal bleeding is described. Within minutes of the intravenous introduction of the radiopharmaceutical, a fraction of the injected activity extravasates at the bleeding site and is eliminated from the circulation. Because of rapid clearance of the radiopharmaceutical from the vascular pool by the reticuloendothelial system, a contrast develops between the site of bleeding and surrounding background. Based on animal experiments, bleeding rates as low as 0.05-0.1 ml/min can be detected with this technique. The sensitivity of this technique in the detection of the site of hemorrhage is significantly higher than arteriography or other techniques that use radioactive blood pool indicators. In this study all patients underwent both scintigraphy and arteriography within several hours. In 20 patients with negative scintigrams, arteriography showed no evidence of bleeding. In the other 23 patients with scintigraphic evidence of hemorrhage, arteriograms were positive for bleeding only in 10. In 19 of the 23 patients, a cause for bleeding was eventually established by other means. This technique appears to offer a simple, practical, and reliable approach to the evaluation of patients with lower gastrointestinal bleeding.

Angiography↗
PubMed1996

Detection of bleeding in patients with major pelvic fractures: value of contrast-enhanced CT.

OBJECTIVE: We performed a retrospective review of trauma patients who had undergone both pelvic angiography and preangiographic i.v. contrast-enhanced CT to determine whether CT can accurately demonstrate the presence or absence of pelvic bleeding in patients with multisystem trauma and major pelvic fractures. SUBJECTS AND METHODS: We reviewed the medical records and imaging studies of all patients, identified through a trauma radiology database, who had undergone pelvic angiography and preangiographic contrast-enhanced CT during a 48-month period. Results of CT scans were recorded by consensus interpretation of three radiologists without knowledge of angiographic findings. Sites of contrast material extravasation seen on CT scans were noted and compared with sites of bleeding or vascular injury identified by selective pelvic angiography. RESULTS: Thirty patients with blunt trauma and pelvic fractures underwent both pelvic angiography and preangiographic CT studies. Findings on pelvic angiograms were positive at 26 sites in 19 patients and included contrast agent extravasation at 23 sites and vessel abnormalities without extravasation at three sites. Preangiographic pelvic CT scans showed contrast agent extravasation at 20 sites in 16 patients. Three patients had no contrast agent extravasation demonstrated by CT but had bleeding demonstrated by angiography. CT detected bleeding in 16 of 19 patients who had extravasation or vascular injury demonstrated by angiography, for a sensitivity of 84%. Results of pelvic angiography were negative in 11 patients, and none had evidence of bleeding on preangiographic CT scans. Two sites of contrast agent extravasation identified in two patients by CT did not show bleeding at angiography, for a specificity of 85% for the detection of bleeding. The overall accuracy of CT for determining the presence or absence of bleeding was 90%. CONCLUSION: Knowledge of sites of ongoing hemorrhage is crucial for optimizing the sequence of diagnostic and therapeutic studies in patients with blunt trauma. Contrast-enhanced CT of the pelvis, which is often performed for hemodynamically stable trauma patients, is a noninvasive technique that is highly accurate in determining the presence or absence of ongoing pelvic hemorrhage. This information can assist in initial management decisions involving patients with multisystem trauma and major pelvic fractures.

Adolescent↗
PubMed1997

Bleeding in portal hypertensive gastropathy evaluated in terms of gastric mucosal microcirculation and coagulation-fibrinolysis system.

Gastric intramucosal bleeding in portal hypertensive gastropathy was investigated in terms of gastric mucosal microcirculation, coagulation-fibrinolysis factors, and local fibrinolysis in patients with liver cirrhosis. The gastric mucosa was examined by endoscopy, and the patients were classified into two groups with or without bleeding. Gastric mucosal blood flow was measured simultaneously with coagulation-fibrinolysis factors or local fibrinolysis in both groups. As gastric mucosal blood flow, the gastric mucosal blood volume (IHb) and the oxygenated hemoglobin concentration (ISO2) were determined by the organ reflection spectrum method. Coagulation-fibrinolysis factors were measured in the blood. For evaluation of local fibrinolysis, gastric biopsy specimens were placed on a standard fibrin plate, and the fibrinolysis area was measured. Compared with the non-bleeding group, the bleeding group showed increased IHb and decreased ISO2 (p < 0.05), suggesting marked congestion of blood flow. Gastric intramucosal bleeding was frequently observed in patients with marked congestion of blood flow and markedly abnormal values of coagulation-fibrinolysis factors. Gastric local fibrinolysis was also significantly enhanced in the bleeding group (p < 0.05). In addition, local fibrinolysis was correlated positively with the gastric mucosal blood volume (r = 0.68, p < 0.05) and negatively with the oxygenated hemoglobin concentration (r = -0.58, p < 0.05). These results suggest the following mechanism of gastric mucosal bleeding in liver cirrhosis and portal hypertension. Congestion of gastric mucosal blood flow is present in liver cirrhosis and portal hypertension. An increase in the microvascular pressure and hypoxia cause release of tissue plasminogen activators from gastric mucosal cells and vascular endothelial cells. As a result, gastric local fibrinolysis is enhanced, causing gastric mucosal bleeding.

Adult↗