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PubMed2003

Factors involved in gastrointestinal bleeding in advanced cancer patients followed at home.

There is a lack of information on the frequency of symptomatic gastrointestinal bleeding in patients with advanced cancer. This group of patients presents several risk factors for developing gastrointestinal bleeding. The aim of this multicenter longitudinal survey was to assess the frequency of gastrointestinal bleeding and possible factors implicated in advanced cancer patients followed at home. A consecutive sample of 439 patients who referred to home palliative care program entered the study. Age, gender, primary cancer and known metastases, possible associated pathologies, history of peptic disease, use of previous or actual nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids, drugs used to prevent gastric complications, the occurrence of hematemesis or melena, significant anemia requiring blood transfusion, and mortality associated with the hemorrhagic event were recorded. Of 377 patients who completed the study, 18 reported gastrointestinal bleeding, and five had significant anemia requiring blood transfusion in three cases. Death was found to be related to bleeding in three patients. NSAIDs, steroids, and gastroprotectors were frequently used, either before or during home care. However, no clear relationship between age, gender, and the use of offender drugs with gastrointestinal bleeding was found. Liver involvement was frequently associated with the risk of developing gastrointestinal bleeding.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2001

Bleeding on probing in smokers and non-smokers in a steady state plaque environment.

An altered gingival inflammatory response to supragingival plaque in smokers had been claimed by several authors. Relatively limited information exists with regard to the consistency of naturally occurring plaque and bleeding upon probing within the oral cavity under usual oral hygiene measures. The aims of the present study were to describe the distribution of tooth surfaces covered by supragingival plaque and gingival units bleeding upon probing in a steady state environment of no dental intervention. In addition relative consistency of plaque and bleeding was investigated. 65 volunteers, 14 women and 51 men in the age range of 19 to 30 years, participated. 33 volunteers were heavy smokers and 32 non-smokers. Clinical examinations revealed mild, plaque-induced gingivitis with no overt destructive periodontitis. Within a 6-month period. presence and amount of plaque, calculus and gingival bleeding was site-specifically assessed four times, i.e., every 8 weeks. Well-defined, symmetric and consistent patterns of plaque and calculus distribution within the oral cavity were observed, which were rather identical in smokers and non-smokers. Smokers had evenly more plaque in all regions of the oral cavity. In contrast, there was no obvious pattern of bleeding upon probing. Consistency of observations was considerably lower than for plaque scores. This was particularly true for smokers, where the association between bleeding scores was generally smaller than in non-smokers. A large portion of the variation of gingival bleeding may be due to presently unknown factors other than plaque and calculus with considerable consequences for preventive programmes.

Adult↗
PubMed2002

Gelatin-thrombin-based hemostatic sealant for intraoperative bleeding in vascular surgery.

Vascular surgical procedures may be prolonged because of intraoperative bleeding that is not easily controlled by cautery or suture ligation. This trial compared the ability of a new hemostat, FloSealTM Matrix (FM), with a known hemostat, Gelfoam(R) plus thrombin (GT), to control intraoperative bleeding. Patients undergoing vascular surgery procedures at four institutions were entered in the trial. After a bleeding site was identified, patients were randomized to one of the study agents: (1) FM, a cross-linked gelatin of bovine origin combined with thrombin, or (2) GT. The assigned agent was applied and the site observed for bleeding at 1, 2, 3, 6, and 10 min. The primary end point was cessation of bleeding within 10 min for the first identified site treated. Secondary end points were cessation of bleeding within 10 min for all sites and time to cessation of bleeding. Patients were assessed for morbidity at 30 days and 6-8 weeks after the operation. Analysis was performed on an intent-to-treat basis for analysis of hemostasis at 10 min and on protocol-valid patients for analysis of time to hemostasis. From our results we concluded that for patients undergoing vascular surgery procedures, the new topical hemostat, FloSeal Matrix, provides more rapid and effective hemostasis than Gelfoam plus thrombin.

Aged↗
PubMed2006

Long-term outcome of argon plasma ablation therapy for bleeding in 100 consecutive patients with colonic angiodysplasia.

PURPOSE: Angiodysplasia is a frequent cause of colonic bleeding. Argon plasma coagulation was reported to be useful in endoscopic hemostasis. However, the long-term outcomes have been poorly evaluated. This study was designed to assess the long-term outcomes of bleeding patients with colonic angiodysplasia treated by argon plasma coagulation. METHODS: A cohort of 100 patients with gastrointestinal bleeding caused by colonic angiodysplasia was studied prospectively. The endoscopic intervention was considered successful if there was no further overt bleeding and hemoglobin concentration was stabilized (primary end point). Secondary end points were the requirement of blood transfusions, the need for surgery, bleeding-related mortality, and overall mortality. RESULTS: Overt bleeding resolved and hemoglobin levels were stabilized without transfusions or iron therapy in 85 of 100 patients (85 percent) after a median follow-up of 20 (range, 6-62) months. Transfusion requirements ceased in 90 percent of patients and only one required surgery. No patient died because of hemorrhage. In the subgroup of patients with anemia, mean hemoglobin levels increased from 9.3 (range, 5.5-12.2) g/dl before treatment to 12.6 (range, 7.4-16.7) g/dl after treatment (P < 0.01). The probability of remaining free of rebleeding at one and two year follow-up was 98 percent (95 percent confidence interval, 96-100) and 90 percent (95 percent confidence interval, 83-97), respectively. Among 118 procedures, only two complications were observed (1.7 percent). CONCLUSIONS: Endoscopic argon plasma ablation therapy is useful in the management of bleeding from colonic angiodysplasia.

Adult↗
PubMed2006

Does adding misoprostol to standard intravenous proton pump inhibitor protocol improve the outcome of aspirin/NSAID-induced upper gastrointestinal bleeding?: a randomized prospective study.

Aspirin and nonsteroidal anti-inflammatory drug (NSAID)-induced gastrointestinal bleeding is recognized as an important health problem. We performed a single-center randomized clinical trial to compare the effect of high-dose intravenous proton pump inhibitor (omeprazole) alone (group 1) with omeprazole in combination with a low-dose prostaglandin analog (misoprostol; group 2) on clinical outcomes in patients with aspirin/NSAID-induced upper gastrointestinal bleeding. Additionally, we evaluated the contribution of Helicobacter pylori eradication therapy on the late consequences. Patients were recruited to the study if they had upper gastrointestinal bleeding with history of taking aspirin or other NSAIDs within the week before the onset of bleeding. All were evaluated in terms of probable risk factors. After the standard treatment protocol, patients with histologically proven H pylori infection were prescribed a triple eradication therapy for 14 days. The primary end points were recurrent bleeding, surgery requirement, and death rates before discharge and at the end of follow-up period. This study lasted for 2 years. A total of 249 patients with upper gastrointestinal bleeding were admitted, and 49.7% of these patients were users of aspirin/NSAIDs. There were 67 patients in group 1 and 56 in group 2. The distributions for gender, age, comorbidity, H pylori infection, and high-risk ulcer rate were similar in both groups. Among aspirin/NSAID users, endoscopy revealed duodenal ulcer in 47 (38.2%), gastric ulcer in 10 (8.1%), and erosive gastropathy in 33 (26.8%). The overall rebleeding occurred in 12.2%, death in 2.4% of the patients. The in-hospital death (P=.414), rebleeding (P=.925), and surgery (P=.547) rates were similar in both treatment groups. After the follow-up period of 3 months, overall rebleeding occurred in 4.1%, and death in 4.8% of the patients. The overall mortality rate was highest in those >65 years old, who were chronic low-dose aspirin users with comorbidity. One died of transfusion-related graft-versus-host disease. In this pilot study, we indicated that adding misoprostol (600 microg/day) to standardized proton pump inhibitor treatment did not improve or change the rebleeding or mortality rates of patients with upper gastrointestinal bleeding related to aspirin/NSAID use. Other prospective studies on higher doses of misoprostol are needed to establish the coeffect. One should bear in mind that all blood products must be irradiated before transfused to the host.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMed2004

Bleeding complications after contemporary pharmacoinvasive therapy for ST elevation myocardial infarction.

BACKGROUND: Pharmacoinvasive therapy for the treatment of ST elevation myocardial infarction (STEMI) is a strategy that combines early restoration of coronary flow via pharmacologically induced thrombolysis with subsequent, prompt percutaneous coronary intervention (PCI). Prior studies suggesting a heightened bleeding risk of PCI performed early after fibrinolysis predated contemporary pharmacoinvasive practice including use of femoral closure devices (CD), fibrin specific thrombolytics, lower doses of heparin and stents. METHODS: Consecutive patients were included in this retrospective registry study if they underwent emergent PCI for ST elevation myocardial infarction (STEMI) followed by immediate use of a groin closure device. Between Oct 1, 2002 and Jan 1, 2003, 27 patients were treated with immediate use of CD after post-thrombolytic PCI, performed within 12 hours of thrombolysis (pharmacoinvasive group). 58 patients were treated with immediate use of CD after primary PCI for STEMI. The two groups were compared with respect to the incidence of successful groin closure, bleeding complications, and clinical outcomes. Bleeding events were categorized according to the TIMI criteria. All baseline clinical and treatment variables were compared between the two groups to determine and the association of these variables (including use of thromblytic therapy) with TIMI major and TIMI minor bleeding was determined. RESULTS: Pharmacoinvasive recanalization with PCI occurred 348 +/- 183 minutes after initiation of fibrinolytic therapy. Glycoprotein IIb/IIIa inhibitors were used less frequently in the patients treated with a thrombolytic agent (59% vs. 90%, p < 0.01). Successful immediate hemostasis was obtained with CD in greater than 85% of patients in both groups (89% for pharmacoinvasive group vs. 86% for primary PCI group, p = 0.89). No patient required vascular surgical intervention. TIMI major bleeding and transfusion requirements were less than 5% in both groups. Antecedent thrombolytic therapy was not a predictor of bleeding complications after PCI. CONCLUSIONS: Use of CD as part of a contemporary pharmacoinvasive strategy is associated with a low rate of major bleeding complications.

Adult↗
PubMed2006

Pseudoaneurysm embolization and vasopressin infusion for lower gastrointestinal bleeding due to recurrence of urinary bladder carcinoma.

We report a case that was successfully treated for massive lower gastrointestinal (LGI) bleeding due to a recurrent urinary bladder carcinoma. Treatment consisted of combination therapy including embolization of an inferior gluteal artery (IGA) pseudoaneurysm and low-dose arterial vasopressin infusion via a sigmoid artery (SA). A 57-year-old man presented with life-threatening sudden, massive LGI bleeding due to an obturator lymph node (LN) metastasis from a urinary bladder carcinoma. Computed tomography showed that the LN recurrence had invaded all the way to the sigmoid colon, and there was a pseudoaneurysm with extravasation inside the recurrence. An angiogram revealed a left IGA pseudoaneurysm. We therefore excluded the pseudoaneurysm by embolization with microcoils. Following this treatment the bleeding decreased, but intermittent LGI bleeding continued. Endoscopic examination showed the tumor with a huge ulcer inside the colonic lumen, and continuous oozing was confirmed. A second angiogram showed no recurrence of the IGA pseudoaneurysm and no apparent findings of bleeding. Then a 3F microcatheter was placed in the SA selectively using a coaxial catheter system, and vasopressin was infused at a rate 0.05 U/min for 12 h. Bleeding completely ceased 2 days later. There were no signs of ischemic gastrointestinal complications. Massive LGI bleeding has not recurred in 5 months.

Aneurysm, False↗
PubMed2005

Small Bowel Bleeding.

The management of patients with small bowel bleeding remains a diagnostic and therapeutic challenge. In most gastrointestinal bleeding episodes, the source of hemorrhage is localized to either the upper gastrointestinal tract or colon; however, in about 5% of cases, upper endoscopy and colonoscopy are nondiagnostic, and the small intestine is the site of bleeding. Patients with suspected small bowel source of bleeding may present with either occult blood loss or recurrent overt gastrointestinal hemorrhage requiring frequent blood transfusions and hospitalizations. Knowing the etiology and site of hemorrhage is essential prior to initiating appropriate therapy. The most common causes of small bowel bleeding are vascular ectasia, tumors, ulcerative diseases, and Meckel's diverticula. For patients with severe obscure bleeding, push enteroscopy with a 220- to 250-cm enteroscope is strongly recommended. This procedure provides not only a thorough examination for diagnosis, but also allows for biopsy, tattooing, and hemostasis of lesions. If enteroscopy is nondiagnostic, capsule endoscopy is recommended. A diagnostic capsule endoscopy will direct appropriate medical, endoscopic, or surgical intervention, depending on whether the lesion is single or multiple, and whether the patient is a surgical candidate for intraoperative enteroscopy. Intraoperative enteroscopy should be strongly considered in patients with recurrent bleeding and a nondiagnostic evaluation. Laparoscopy and intraoperative enteroscopy is highly recommended in young patients (< 50 years of age) because there is an increased frequency of small bowel tumors and Meckel's diverticulum which are amenable to surgical therapy.

Journal Article↗
PubMed1980

Aortic stenosis associated with gastrointestinal bleeding. A survey of 612 patients.

A retrospective study was done in order to examine the association between aortic stenosis (AS) and gastrointestinal tract (GIT) bleeding. Four groups of patients included a group of 152 patients with AS, a control group of 152 patients with MS, and another two groups of 154 patients each with and without GIT bleeding. GIT bleeding of known and of idiopathic sources was significantly more prevalent among patients with AS (three and four patients, respectively) than among those with MS (none). Moreover, AS was significantly more prevalent in association with idiopathic GIT bleeding (seven out of 24, 29.1%), in comparison to its association with bleeding from a known source (two out of 130, 1.5%), and its incidence in routinely admitted patients without GIT bleeding (three out of 154, 1.9%). This study supports the assumption that GIT bleeding may be associated with AS.

Adolescent↗
PubMed1983

Influence of aspirin on platelets and the bleeding time.

Aspirin influences the bleeding time, presumably through the inhibition of prostaglandin biosynthesis and the resultant platelet secretion reaction. This can be measured by prolongation of the bleeding time and changes in platelet function results. Despite these changes, bleeding is rarely a problem in patients who have normal hemostatic mechanisms. To investigate this, we have studied the technical variables associated with the determination of the bleeding time. Both venostasis and direction of the incision play a major role in the bleeding time prolongation induced by aspirin. When a bleeding time determination is performed with vertical incision without venostasis, there is almost no detectable prolongation of the bleeding time. These studies support our previous observations that aspirin has a mild influence on primary hemostasis.

Animals↗
PubMed1987

Significance of occult gastrointestinal bleeding during anticoagulation therapy.

A prospective study was undertaken to determine the effect of anticoagulation therapy on the prevalence of occult gastrointestinal bleeding and to ascertain the causes of bleeding. During a six-month period, 256 patients who had received anticoagulants were screened for occult bleeding with guaiac-impregnated cards. Twenty-one (12 percent) of the 175 patients who had received anticoagulants and who voluntarily completed the cards had occult gastrointestinal bleeding compared with only two (3 percent) of 74 control patients who had not received anticoagulants. The mean prothrombin time and partial thromboplastin time did not differ significantly in the patients who had received anticoagulants with and without subsequent bleeding. Fifteen of 16 patients who had received anticoagulants and who underwent diagnostic evaluation had previously undiagnosed lesions in the intestinal tract. These results indicate that occult gastrointestinal bleeding in a patient who has received an anticoagulant should not be attributed to the anticoagulant; instead, such bleeding often indicates the presence of significant intestinal disease.

Adult↗
PubMed1987

Risk of acute stress bleeding and nosocomial pneumonia in ventilated intensive care unit patients: sucralfate versus antacids.

In a prospective, controlled, randomized study of the prophylaxis of stress bleeding, 100 ventilated high-risk patients in a surgical intensive care unit received, on a daily basis, 1 g of sucralfate suspension (n = 50) every four hours, or an antacid (n = 50) every two hours. The mean duration of the treatment was about six days in both of the groups. Gastric pH was determined every eight hours. Bleeding was defined as macroscopically visible bleeding. The intragastric pH was less than 4 significantly more often in patients treated with sucralfate. In each group, one case of macroscopically visible bleeding occurred. Both of the patients had a very high risk of bleeding. None of the bleedings influenced the outcome of the patients. When patients with primary thoracic trauma or pneumonia were excluded, nosocomial pneumonia developed in significantly fewer (p less than 0.05) patients in the sucralfate group (three of 29) than in the antacid group (11 of 32). In four of the latter patients, pneumonia influenced the outcome of the patients. Sucralfate provides adequate protection against stress bleeding while also minimizing the danger of pneumonia caused by infection via the gastropulmonary route.

Adult↗
PubMed1992

Efficacy of intraoperative enteroscopy in diagnosis and prevention of recurrent, occult gastrointestinal bleeding.

The role and effectiveness of intraoperative enteroscopy in the evaluation of gastrointestinal (GI) bleeding of obscure origin is not clearly defined. Our aim was to determine if intraoperative enteroscopy is effective in identifying a source, which would lead to therapy and prevent recurrent gastrointestinal hemorrhage. Forty-four patients (median age: 64 years) underwent intraoperative enteroscopy. Median number of preoperative blood transfusions, duration of bleeding (months), and prior hospitalizations for GI hemorrhage were 19, 15, and 2, respectively. Many patients had risk factors associated with bleeding. All had undergone an extensive preoperative evaluation. Intraoperative enteroscopy was completely negative in 13 (30%). A site-specific source was seen in the small bowel in 31 patients (70%); 27 patients had lesions amenable to segmental resection with or without other means of definitive management. Only 6 of 31 patients (19%) had lesions that were actively bleeding. Twenty-three (52%) patients have had recurrent bleeding requiring transfusion (median follow-up: 21 months). Although intraoperative enteroscopy identified specific mucosal abnormalities in 70% of patients, the therapeutic efficacy in preventing recurrent hemorrhage was only 41%. Intraoperative enteroscopy is an effective tool in selected patients with occult GI bleeding and correctly identifies a treatable source and prevents recurrent bleeding in 41% of patients.

Endoscopy, Gastrointestinal↗
PubMed1990

Microdose intravaginal levonorgestrel contraception: a multicentre clinical trial. IV. Bleeding patterns. World Health Organization. Task Force on Long-Acting Systemic Agents for Fertility Regulation.

A multicentred clinical trial was conducted in 12 countries to assess the contraceptive efficacy and side effects of a low-dose levonorgestrel-releasing vaginal ring. Contraceptive efficacy and side effects, expulsions and removals, and the relation between pregnancy rate and admission body weight of the women have been reported previously. The effect of ring use on vaginal bleeding patterns as observed from daily menstrual diaries kept by the women is the object of this paper. A total of 1005 women were fitted with the ring and 702 of them provided a menstrual diary suitable for analysis. The description of the bleeding patterns is made using a 90-day reference period approach and following the guidelines published by WHO. In addition the longest bleeding/spotting episode and longest bleeding/spotting-free interval are calculated over the entire diary length. Half of the ring users have vaginal bleeding patterns similar to normal untreated patterns. A quarter experience irregular bleeding, 10% have prolonged cycles and 10% have shortened cycles. Over one year of continuous use, there appears to be no significant trend in these patterns. Users with the worst bleeding patterns tend to discontinue first during the clinical trial and are influenced by their more recent experience of vaginal bleeding irregularities. Life-table analysis of discontinuation rates gives an underestimation of the true incidence of bleeding irregularities. Some comments are made on the limitations of the methods of analysis of menstrual diaries.

Clinical Trials as Topic↗
PubMed1993

Women's opinion on withdrawal bleeding with hormone replacement therapy.

The objective of the study was to assess the opinion of women about the use of hormone replacement therapy (HRT) in relation to continuation or re-induction of bleeding periods after menopause. The design was a population-based cross-sectional study using a postnatal questionnaire in Krimpen aan den IJssel, a commuter suburb of Rotterdam. The participants were all 2729 women living in Krimpen aan den IJssel aged 45-60 years, of whom 1947 (71.3%) responded. The main outcome measure was an opinion on monthly or trimonthly withdrawal bleedings with HRT. The results showed 16.9% of all women have no or little objection to use of HRT with monthly withdrawal bleedings. There is a marked difference between premenopausal women (32.4% have no or little objection) and postmenopausal women (only 9.2% have no or little objection). Trimonthly cycles during HRT tend to be perceived as more acceptable (41.4% of premenopausal women and 11.8% of postmenopausal women have no or little objection). It is concluded that a reasonable proportion of premenopausal women accept continuation of periodic bleeding with HRT. There is a preference for trimonthly cycles rather than monthly withdrawal bleedings. Most postmenopausal women object to having withdrawal bleedings with HRT, irrespective of a monthly or trimonthly cycle. Research should continue on schedules without withdrawal bleedings.

Estrogen Replacement Therapy↗
PubMed1996

Effect of maternal age and parity on the risk of uteroplacental bleeding disorders in pregnancy.

OBJECTIVE: To examine the risk of placental abruption, placenta previa, and uterine bleeding of unknown etiology in relation to advanced maternal age and parity in a large, population-based study. METHODS: Data for this study were derived from the Nova Scotia Atlee perinatal provincial data base, Canada, an ongoing project on human reproduction. Women who delivered between 1980 and 1993 (n = 123,941) in the province of Nova Scotia were included in the study, with the exception of pregnancies resulting in multiple births (n = 2859) and those missing data on maternal age or parity (n = 14). Multivariable logistic regression models based on the method of generalized estimating equations were used to generate odds ratios after adjustment for multiple confounders. RESULTS: The frequency of abruption was increased slightly among younger women (relative risk [RR] 1.3, 95% confidence interval [CI] 1.0-1.7), compared with women ages 25-29 years, but there was no increase with advancing maternal age. In contrast, the risk of placenta previa increased dramatically with advancing maternal age, with women older than 40 years having a nearly ninefold greater risk than women under the age of 20, after adjustment for potential confounders, including parity. Uterine bleeding of unknown etiology was not associated with advanced maternal age, except for a slight increase among women over 40 (RR 1.3, 95% CI 1.0-1.6). The risk of placenta previa and placental abruption was increased with higher parity among younger women only, but uterine bleeding of unknown etiology was more weakly associated with higher parity. In addition, an analysis of the joint effects of age and parity on placental abruption indicated a strong parity effect for women under 30 years, whereas the risk of placenta previa increased with increasing parity up to age 35 years. Uterine bleeding of unknown etiology also indicated a parity effect that was restricted to women under 25 years. CONCLUSION: Multiparity is associated with the risk of placenta previa and, to a lesser extent, placental abruption, but not with other uterine bleeding. Increasing maternal age is associated independently with the risk of placenta previa, but not with either of the other two conditions. Finally, the increased risks of uteroplacental bleeding disorders with advanced parity among the younger women (ie, 20-25 years, parity 3+) may reflect effects of close pregnancy spacing, or confounding by unmeasured factors that characterize women who have many pregnancies at a relatively young age. Overall, the findings suggest that the three uteroplacental bleeding disorders do not share a common etiology in relation to maternal age and parity, and that placenta previa is linked to aging of the uterus and the effects of repeated pregnancies.

Abruptio Placentae↗
PubMed1993

Diagnostic significance of nailfold bleeding in scleroderma spectrum disorders.

BACKGROUND: The early detection of scleroderma spectrum disorders (SSD) is important. OBJECTIVE: Our purpose was to determine the prevalence of nailfold bleeding in SSD. METHODS: We examined patients for nailfold bleeding in the following three groups: (1) 81 patients with SSD including 50 patients with scleroderma, 10 with mixed connective tissue disease, and 21 with Raynaud's phenomenon having specific antinuclear antibody (ANA); (2) 99 patients with other connective tissue diseases or primary Raynaud's phenomenon; and (3) 200 patients with common skin diseases. RESULTS: The frequency of nailfold bleeding was significantly higher in SSD (75.3%) than in other connective tissue diseases (12.1%) and in controls (3.0%). The presence of nailfold bleeding in two or more fingers showed a 98.3% specificity for SSD. Among the patients with SSD, the incidence of nailfold bleeding in scleroderma, mixed connective tissue disease, and Raynaud's phenomenon with specific ANA was similar. Nailfold bleeding strongly correlated with the presence of anticentromere antibody. CONCLUSION: The presence of nailfold bleeding is useful for the early detection of SSD.

Antibodies, Antinuclear↗
PubMed1996

The bleeding risk in chronic haemodialysis: preventive strategies in high-risk patients.

Haemodialysis (HD) patients are at an increased risk of bleeding because of uraemic bleeding tendency and systemic anticoagulation caused by intermittent heparinization. Additional risk factors may be aspirin or coumarin use for the prevention of fistula thrombosis, diffuse intravascular coagulation, recent trauma, postsurgical state, inadequate control of hypertension, gastrointestinal lesions, diabetic retinopathy, renal cystic disease, and uraemic pericarditis. In HD patients with an active bleeding focus blood transfusion, desmopressin acetate (DDAVP), conjugated oestrogens, and dialysis treatment can limit the bleeding risk. Strategies to reduce the bleeding risk conveyed by systemic anticoagulation during HD are regional heparin anticoagulation and minimal heparinization. In our opinion, dialytic modalities that completely preclude systemic anticoagulation, i.e. peritoneal dialysis (PD), heparin-free HD, and HD with regional anticoagulation with prostacyclin, mesilates, or citrate, are indicated for patients who are actively bleeding, or who are within 3 days from a bleeding episode, or a surgical or accidental wound, or who are less than 2 weeks from cerebral or retinal haemorrhage, and for patients with incompletely treated proliferative diabetic retinopathy or uraemic pericarditis.

Cerebral Hemorrhage↗