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PubMed1987

[A study of intrapartum and postpartum bleeding based on changes in blood coagulation and fibrinolysis during pregnancy].

The relationship between changes in blood coagulation and fibrinolysis during pregnancy and intrapartum-postpartum bleeding was studied as a trial prediction of abnormal bleeding during vaginal delivery in 27 subjects without any complications. The following results were obtained: In the third trimester, shortening of prothrombin time and activated partial thromboplastin time, increases in fibrinogen, platelet epinephrine, collagen aggregation, and plasminogen, and a decrease in alpha 2-plasmin inhibitor were marked as compared with those in the first trimester. In the same subjects, the relationship between changes in blood coagulation and fibrinolysis in the first and third trimesters and intrapartum-postpartum bleeding was studied by the independent matched pair test. There were significant correlations (p less than 0.005, p less than 0.001) between prothrombin time (r = -0.68862) and activated partial thromboplastin time (r = -0.77027). In the subjects whose prothrombin time and activated partial thromboplastin time in the third trimester were shorter than those in the first trimester, intrapartum and postpartum bleeding increased. The subjects whose prothrombin time and activated partial thromboplastin time in the third trimester were less by more than 0.52 seconds and more than 3.98 seconds, respectively, than those in the first trimester experienced abnormal bleeding exceeding 500 ml during delivery. In the intrapartum and postpartum bleeding group, shortening of prothrombin time and activated partial thromboplastin time, decreases in fibrinogen and alpha 2-plasmin inhibitor and an increase in platelet aggregation were more significantly observed than in the intrapartum and postpartum normal bleeding groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Antithrombin III↗
PubMed1985

Esophageal transection versus injection sclerotherapy in the management of bleeding esophageal varices in patients at high risk.

In a prospective randomized trial of 76 patients at high risk with bleeding esophageal varices, transection of the esophagus with the EEA stapling apparatus was compared with injection sclerotherapy in the management of patients with Child's class B and C liver status. Thirty-nine patients underwent transection and 37 patients, sclerotherapy with a total of 92 injection procedures (2.4 per patient). The perioperative mortality (less than 30 days) was 28.9 per cent overall; 33.3 per cent for esophageal transection and 24.3 per cent for injection sclerotherapy (chi 2 = 0.375, p greater than 0.05). Gross ascites, severe encephalopathy and emergency operations were associated with a high mortality in the transection group, but other risk factors such as age and hypersplenism did not influence the outcome in either group. Only patients in Child's class C died after transection, but patients who died in the sclerotherapy group (mainly from recurrent bleeding) included patients from both Child's class B and C. Early recurrence of nonfatal bleeding affected one of 39 patients (2.5 per cent) after transection but was evident in 18 of 37 patients (48.6 per cent) after sclerotherapy (chi 2 = 19.12, p greater than 0.0005) and six patients died. Hemorrhage did not recur after transection during a follow-up period of two years, but a further 22 episodes of bleeding were recorded in 13 patients receiving sclerotherapy with five deaths. Postoperative complications and long term morbidity were similar in the two groups. Including readmissions for bleeding and repeat procedures, the mean hospital stay per patient was shorter for transection (14.5 versus 19.1 days) and the requirements for blood were less (1.9 units per patient versus 3.6 units per patient) than for sclerotherapy. It is concluded that esophageal transection effectively protects against short term recurrence of bleeding. Preoperative control of gross ascites will further reduce the mortality and comatose patients should be excluded from operation. Sclerotherapy provides little if any protection against recurrent bleeding and its use in the management of variceal hemorrhage in patients with advanced liver disease remains questionable. It is recommended as a temporary measure in patients at high risk until such time that more effective surgical treatment can be performed.

Adolescent↗
PubMed1985

Bleeding complications from warfarin anticoagulation in patients with malignancy.

Bleeding complications from warfarin anticoagulants were analyzed in 431 patients with carcinoma of the lung, colon, prostate and head and neck who were admitted to a randomized, controlled therapeutic trial of this agent. A total of 215 patients were randomized to the warfarin-treated group and 216 to the control groups. The mean prothrombin time was significantly prolonged (p = 0.0001) for warfarin-treated patients. The duration of warfarin administration was 64.9% of the total followup period providing 101 patient-years of experience with warfarin in cancer. Both the overall incidence of bleeding episodes (58% of warfarin-treated versus 30% of control) and the incidence of major bleeding episodes (42% versus 14%, respectively) were significantly increased in the warfarin-treated group (p = less than 0.001). The incidence of major bleeding was 1.86 per patient-year on warfarin. The most common sites of bleeding (in descending order) were the gastointestinal tract, the urinary tract, the nasal passages and skin. Hemorrhage occurred in association with the terminal event in 10 warfarin-treated and 12 control patients. Warfarin anticoagulation may have contributed to terminal bleeding in 3 (1.4%) patients. There was no difference in mean hemoglobin or hematocrit values for patients with versus patients without bleeding episodes.

Clinical Trials as Topic↗
PubMed1983

Use of technetium-labeled autologous red blood cells in detection of gastrointestinal bleeding.

Twenty patients with occult gastrointestinal bleeding underwent diagnostic evaluation with autologous TcRBC imaging, which identified a locus of bleeding in 19. Bleeding was demonstrated in the esophagogastroduodenal area in four patients, the cecum in four patients, the ascending colon or hepatic flexure in nine patients and the descending colon in two patients. In the six patients who underwent surgical intervention, the source of bleeding had been correctly located by imaging. The advantages of imaging over those of conventional arteriography included its minimally invasive nature and its ability to detect areas of intermittent minimal bleeding for a period of 30 hours. The major disadvantages of the technique were that localization of the site of bleeding was not as precise as that obtained with arteriography, imaging could not be used as a treatment modality and the nature of the lesion could not be defined. However, we believe that, as an adjunct to conventional angiography and other techniques, autologous TcRBC imaging will improve the localization of obscure foci of gastrointestinal bleeding. Studies are underway to determine the proper place of TcRBC imaging in the gastroenterologic armamentarium. Its noninvasive nature and sensitivity to intermittent hemorrhage suggest that it may become the initial investigative modality of choice in many instances.

Adult↗
PubMed1984

The role of colonoscopy in the diagnosis and management of lower intestinal bleeding.

Colonoscopy and roentgenographic studies are complementary techniques in the evaluation of disorders involving the large bowel. The exact roles of these methods in the diagnosis and management of lower intestinal bleeding, however, remain to be established. In this paper, we have formulated various roles for colonoscopy in lower intestinal hemorrhage depending upon the rate and activity of the bleeding according to whether the episode is: 1) recent minor bleeding or recurrent minor or occult bleeding; 2) severe bleeding which has stopped; 3) severe and active bleeding. In addition, we discuss colonoscopic therapy of bleeding lesions and intraoperative endoscopy of the small and large bowel.

Adolescent↗
PubMed1983

Selective management of lower gastrointestinal bleeding.

The management of lower gastrointestinal bleeding has evolved from a number of technological advances allowing precise diagnosis and localization of the bleeding site. This study of 40 angiographically demonstrated lower gastrointestinal bleeding lesions reinforces much of the data indicating the diagnostic and therapeutic trends. Twenty-four patients had bleeding diverticula with angiographic demonstration in 11 patients. Seven cases of vascular ectasia were identified, and nine patients had a variety of significant bleeding sites other than the two main sites that were listed. Pitressin was useful for control of bleeding in six of seven diverticular patients but was less useful in the vascular ectasia group in which only one patient was actively bleeding. Total abdominal colectomy and segmental resection were successful in control of hematochezia in 24 of 25 operative cases. Sixteen patients did not require surgical treatment.

Aged↗
PubMed1981

[Therapy of acute bleeding from esophagus varices (author's transl)].

Acute bleeding from esophagus varices in portal hypertension is still a considerable therapeutic problem, and quite different approached to treatment are being followed. We use the following approach general procedures like treatment of shock, treatment of coagulation disorders etc.; emergency endoscopy; submucosal sclerosing if varices can be identified endoscopically as the source of bleeding. If bleeding cannot be stopped in this way a Sengstaken probe is applied for 4-6 hours, and after that sclerosing of the bleeding area is tried again. If bleeding does not stop at that time yet, the vena coronaria ventriculi or the venae gastricae breves are sclerosed by the transhepatic route. In almost all cases bleeding can be stopped successfully if this sequence of procedures is followed. After bleeding has been stopped, surgery establishing a portacaval shunt may be taken into account.

Dilatation↗
PubMed1981

Evaluation and initial management of patients with upper gastrointestinal bleeding.

Evaluation and initial management of a patient with gastrointestinal (GI) bleeding progresses in stepwise fashion, beginning with assessment of the severity of bleeding. For this, the hematocrit must be considered in conjunction with factors reflecting vascular volume such as blood pressure and heart rate. Resuscitation to maintain tissue oxygenation should than be instituted with intravenous fluids and blood products in amounts appropriate to the severity of hemorrhage. Vital signs are monitored carefully. During resuscitation, attention is directed to determining whether bleeding comes from the upper or lower GI tract. If upper GI bleeding has been proven, gastric lavage is performed through a large-bore orogastric tube using copious quantities of fluid. Empiric therapy for upper GI bleeding, usually aimed at reducing gastric acidity, may be instituted as decisions regarding diagnostic techniques are considered. Endoscopy is a more accurate diagnostic tool than barium x-rays and can be performed in all but massively bleeding patients. There is overwhelming evidence, however, that, at least in patients who cease bleeding during resuscitation, endoscopy does not alter outcome. Since endoscopy is expensive, it should be reserved for selected patients in whom a specific diagnosis will dictate an important change in therapy.

Antacids↗
PubMed1981

IUD use and unexplained vaginal bleeding.

The Women's Health Study, a concurrent case-control study at 16 hospitals in 9 cities across the United States, examined the relationship between intrauterine contraceptive device (IUD) use and unexplained vaginal bleeding severe enough to require hospitalization. There were 545 eligible cases and 3453 controls. Analysis of all patients showed no association between IUD use and hospitalization for unexplained vaginal bleeding. When cases were analyzed separately with regard to prior episodes of vaginal bleeding, those patients with a history of vaginal bleeding had a decreased risk of hospitalization. Among cases, no significant differences between IUD users and nonusers were found in rates of anesthesia, blood transfusion, dilatation and curettage, or hysterectomy. The significant decreased risk between current IUD use (within 3 months before the study) and hospitalization for unexplained vaginal bleeding among women with a history of vaginal bleeding may reflect selective nonprescription for IUDs related to past episodes of vaginal bleeding.

Adult↗
PubMed1995

Three decades of experience with emergency portacaval shunt for acutely bleeding esophageal varices in 400 unselected patients with cirrhosis of the liver.

BACKGROUND: Emergency treatment of acute bleeding is of singular and paramount importance in the therapy of portal hypertension and esophagogastric varices. Accordingly, for more than three decades we have conducted prospective studies of emergency therapy, and particularly of emergency portacaval shunt (EPCS). STUDY DESIGN: Emergency portacaval shunt was performed upon 400 patients with cirrhosis of the liver and acutely bleeding esophagogastric varices according to three principles: operation within eight hours of initial contact; unselected patients, meaning that no patient with variceal bleeding caused by hepatic disease was excluded from EPCS, and prospective study, meaning that a well-defined protocol was consistently used and data were collected on-line. Patients were divided into an early group of 180 treated from 1963 to 1978 and a recent group of 220 treated from 1978 to July, 1990, with similar characteristics, but strikingly different outcome. Follow-up rates at one, five, and ten years were 100, 98, and 97 percent, respectively; 96 percent of patients underwent EPCS five or more years ago. Proof of acute variceal bleeding and of cirrhosis of the liver (alcoholic in 95 percent) was obtained in every patient. Child's risk classes determined quantitatively were A in 11 percent of the patients, B in 65 percent, and C in 24 percent. All patients had a direct portacaval shunt, side-to-side in 85 percent, which reduced the mean portal vein to inferior vena cava pressure gradient from 271 to 21 mm saline solution. RESULTS: All but four patients (99 percent) had immediate and permanent control of variceal bleeding. Thrombosis of the shunt occurred in only two patients (0.5 percent). Survival rates at 30 days, five years, ten years, and 15 years in the early group were 58, 40, 30, and 30 percent, respectively, while in the recent group they were 85, 78, 71, and 57 percent, respectively (p < 0.0001). Other striking gains in the recent group were abstention from alcohol, improvement in liver function and improvement in Child's class, all in 70 percent of patients. Recurrent portal-systemic encephalopathy occurred in 9 percent of the early group and 8 percent of the recent group. CONCLUSIONS: Emergency portacaval shunt substantially improved survival and quality of life of patients with cirrhosis of the liver and bleeding varices. Our results are attributable to rapid and simplified diagnosis, prompt operation, an organized system of care, and rigorous, lifelong follow-up evaluation that emphasized abstinence from alcohol and dietary protein control. Transplantation of the liver is infrequently required in patients whose bleeding is permanently controlled.

Adult↗
PubMed1976

Studies on the prolonged bleeding time in von Willebrand's disease.

Three experimental models have been employed to investigate the mechanism of the prolonged bleeding time in patients with von Willebrand's disease (vWd). 1-deamino-8-D-arginine vasopressin (DDAVP), a synthetic analogue of the antidiuretic hormone, was administered to normal volunteers and patients with vWd in order to induce a short-term, endogenous increase of factor VIII procoagulant activity (VIIIAHF), factor VIII-related antigen (VIIIAGN), and Willebrand factor (VIIIVWF); and to investigate the relationship between bleeding time and plasma variations of factor VIII-associated properties. In normal subjects DDAVP administration was followed by a marked increase of VIIIAHF, VIIIAGN, and VIIIVWF; yet the bleeding time remained unchanged. The same parameters were also raised in two groups of patients with vWd. In a third group of patients with severe recessive vWd, factor VIII-associated properties, which were not measurable before the infusion, were unmodified. The bleeding time remained unchanged in all vWd patients. To investigate the effect of the exogenous increase of factor VIII-associated properties, cryoprecipitate was given to ten vWd patients before dental surgery. Despite the marked increase of VIIAHF, VIIAGN, and VIIVWF observed after the infusion, bleeding time was not shortened. Finally, in order to evaluate the hypothesis that factor VIII may exert its effect on primary hemostasis locally in the vessel wall, VIIIAGN and its relationship with the bleeding time were studied by direct immunofluorescence in gum-biopsy specimens obtained in vWd patients before cryoprecipitate infusion. No reaction could be elicited in five patients with severe, recessive vWd, whereas venules and arterioles stained positively in five patients with a moderate form of the disease. Immunofluorescence microscopy was also carried out in specimens obtained after cryoprecipitate at a time when the plasma defects were corrected but the long bleeding time was not modified; no reaction was detectable on the vessel wall of the three patients who were negative before the infusion.

Adult↗
PubMed1993

Hemophilia with factor VIII and factor IX inhibitors, incidence, bleeding problems and management.

Among 117 cases of hemophilia, there were 7 hemophilia A and 2 hemophilia B with factor VIII and factor IX inhibitors diagnosed at the Department of Pediatrics, Siriraj Hospital, Bangkok, Thailand. The overall incidence of hemophilia with inhibitors was 7.7%. Eight cases (6 hemophilia A. 2 hemophilia B) were severe hemophilia and 1 moderate hemophilia A. The average age of the inhibitor detection was about 5 years. Of the 9 cases, 7 had high inhibitor titers and 2 had low inhibitor titers. The frequency of bleeding problems before and after inhibitor detection were not different. The bleedings included hemarthrosis, mucosal bleed, hematoma, oozing from wound, hematuria and intracranial hemorrhage. The treatment of hemarthrosis in hemophilia A with low inhibitor titers was the combination of short course of prednisolone and single large dose factor VIII. In high inhibitor titer patients with acute hemarthrosis (both hemophilia A and hemophilia B), the treatment consisted of prednisolone short course and single high dose of PCC. For bleeding control in both high and low inhibitor titer with mucosal bleeds, oozing from wounds, central nervous system bleeding and hematuria, the combination was used of high dose factor VIII or factor IX for 2 days, and tranexamic acid, prednisolone, cyclophosphamide were required. In life-threatening hemorrhage and surgical operation, plasmapheresis and large dosage factor VIII or factor IX were the treatment of choice. All supportive measures were also important in every case of mucosal bleeds, wounds and surgical operations. The result of treatment revealed one death from massive intracranial hemorrhage and 8 survivals, with joint contracture in 2 cases. All still have inhibitor detected, but in low titer.

Child↗
PubMed1994

Endoscopic sclerotherapy in upper gastrointestinal bleeding due to the Mallory-Weiss syndrome.

OBJECTIVES: Therapeutic endoscopic techniques have changed the need for emergency surgery in gastrointestinal bleeding episodes. However, there is only little information about endoscopic therapies in severe gastrointestinal bleeding due to the Mallory-Weiss syndrome. The aim of this clinical study was to assess the usefulness of early endoscopic examination and sclerotherapy for severe or recurrent bleeding due to the Mallory-Weiss syndrome. METHODS: We studied all 50 cases of gastrointestinal bleeding secondary to the Mallory-Weiss syndrome seen in 2175 consecutive emergency endoscopic examinations performed in a University Hospital over a 3-year period. Endoscopic sclerotherapy (1/10000 adrenaline + 1% polidocanol) was performed in all patients with active bleeding or visible vessel at endoscopic examination. The remaining patients were medically treated. RESULTS: Active bleeding or a visible vessel were found in 13 patients; definitive hemostasis was obtained in all cases with sclerotherapy. The remaining 37 patients were successfully treated by conservative therapy. On admission, the severity of the hemorrhagic episodes was significantly higher in patients treated with sclerotherapy than in those who did not require this procedure. An esophageal perforation, successfully managed by conservative means, was the only complication recorded in the subset of patients undergoing sclerotherapy. CONCLUSIONS: Severe bleeding due to Mallory-Weiss syndrome can be successfully treated by sclerotherapy. Early endoscopic examination is an accurate procedure in identifying patients who do not require sclerotherapy.

Adult↗
PubMed1994

Biphasic diurnal periodicity in bleeding from peptic ulcer.

OBJECTIVE: To evaluate if there was periodicity in the manifestations of gastrointestinal bleeding (hematemesis and melena). METHOD: This is a multicenter prospective study carried out in the Endoscopy Units of eight hospitals. At the time of the emergency endoscopy, the following data were collected: age, sex, endoscopic diagnosis, solar hour of the first hematemesis (vomiting of bright red or tarry black material) and of the first melena (black or bloody soft stools), and any drugs taken during the week before the bleeding episode, regardless of the dose. RESULTS: 806 patients were studied. Bleeding was from peptic ulcer in 405 patients (50%), from esophageal varices in 197 (24%), and from other sources in the remainder. Analysis using single cosinor statistics showed a nonrandom distribution in bleeding from peptic ulcer, whether presenting first with hematemesis (p = 0.02) or melena (p = 0.03). There were two peaks at 6:45 AM and 6:45 PM for hematemesis and at 7:25 AM and 7:25 PM for melena, representing a biphasic diurnal (ultradian) rhythm. CONCLUSIONS: This study shows that bleeding due to peptic ulcer has a biphasic diurnal periodicity. This has potential importance for the pathogenesis of bleeding, for the management of gastrointestinal hemorrhage and the administration of drugs known to cause peptic ulcer bleeding.

Adolescent↗
PubMed1993

Investigation of gastrointestinal bleeding in patients with end stage renal disease.

In order to evaluate the source and course of gastrointestinal bleeding in patients with established renal insufficiency, we reviewed data on 40 patients with renal failure and gastrointestinal bleeding seen over 2 yr. A randomly selected control group of 39 patients without renal failure was used for comparison. Medical records of our University Hospital were reviewed, and patients with a documented gastrointestinal bleed and renal insufficiency (creatinine greater than 1.7 mg/dl) were included in this study. Panendoscopy was the most valuable procedure in terms of establishing a diagnosis as to the cause of bleeding. Colonoscopy was of questionable value unless the bleed was clearly of lower intestinal origin. Recurrent bleeding during the index admission occurred with the same frequency in both groups of patients. Both groups used nonsteroidal anti-inflammatory agents frequently. The findings and outcome for this group of patients with renal failure was comparable to the control patients with gastrointestinal bleeding.

Adult↗
PubMed1995

Portal-systemic encephalopathy and gastrointestinal bleeding after cardioselective beta-blocker (metoprolol) administration to patients with portal hypertension.

The use of the non-selective beta-blocker propranolol has been widely recommended to prevent gastrointestinal bleeding in patients with portal hypertension. We conducted a prospective, randomized controlled trial of metoprolol, a selective beta-blocker for prevention of gastrointestinal bleeding from portal hypertension in 29 non-selected patients with liver disease and previous gastrointestinal bleeding. Fifteen patients received placebo treatment for 40 +/- 18 months and 14 patients received metoprolol for 31 +/- 17 months. A sustained reduction in resting pulse was observed in those patients treated with metoprolol. There was no significant difference in acute re-bleeding episodes between the two groups. Of the 14 patients treated with metoprolol, three (21%) re-bled, all three requiring blood transfusion. Four (26.5%) of the 15 patients treated with the placebo re-bled, two cases with acute bleeding and the remaining two cases presented a positive stool guaiac test. All cases who bled during the metoprolol therapy required exclusion from the trial, and surgical procedures or sclerotherapy as well. After both metoprolol or placebo treatments, similar deterioration of standard liver function tests was observed. Further, at the end of the trial, 11 patients on metoprolol (78%) and four of the patients treated with the placebo (27%) required treatment for clinical portal-systemic encephalopathy (p < 0.01). The risk of poor sympathomimetic response after cardioselective beta 1-blocker during acute bleeding episodes and the appearance of hepatic encephalopathy deserve further investigation. The selective beta-blocker metoprolol seems to be an inadequate choice to prevent gastrointestinal re-bleeding in patients with portal hypertension.

Adrenergic beta-Antagonists↗
PubMed1996

Colonoscopic findings in patients with lower gastrointestinal bleeding send to a hospital for their study. Value of clinical data in predicting normal or pathological findings.

BACKGROUND: Lower gastrointestinal bleeding is a highly frequent clinical problem that may reflect serious pathology in the colon. Colonoscopy is generally accepted as the diagnostic procedure of choice. Decisions as to whether to carry out colonoscopy or not, are not well defined. METHODS: 536 colonoscopies, made to discover the cause of lower gastrointestinal bleeding were analyzed and a final 457 included in the study. All of these patients came to the hospital because they had presented at least in one occasion, one episode of rectal bleeding, and were send by the specialist of the zone, in order to achieve a correct diagnosis of its process. In all cases the following associated symptoms were analyzed: the presence of diarrhea, constipation, abdominal pain and rectal mass on examination. The characteristics of lower gastrointestinal bleeding were analyzed in a subset of 150 consecutive patients. RESULTS: Mean age was 59 +/- 16.9 years. 54.5% were male and 45.5% female. The exploration was normal until the cecum in 146 patients (32%). In the remaining 311, the findings were: polyps (25.1%), diverticular disease (24%), neoplasia (12.6%), inflammatory bowel disease (9.4%), unspecific proctitis (2.4%), ischemic colitis (2.4%), angiodysplasia (1.9%), infectious colitis (1.1%), and miscellaneous (0.7%). An age of less than 40 years and the existence of anal pathology were significantly more frequent among patients with a normal examination (p < 0.001), but with a sensitivity of only 66%. No differences were found among patients with disordered bowel frequency or abdominal pain in relation to the colonoscopic findings. Previous presence of a rectal mass when the examination proved abnormal (p=0.06). Intermittent bleeding and the presence of blood in the stools were more frequent in patients with normal examination (p= 0.07 and p< 0.05, respectively). No significant differences in relation to colour, duration of bleeding, or to whether toilet paper was stained with blood were found. CONCLUSIONS: 1) The more frequent endoscopic findings were polyps and diverticular disease. 2) Clinical data are of little value in predicting a normal examination. 3) Total colonoscopy appears to be the first procedure of choice in all patients with lower gastrointestinal bleeding, irrespective of the clinical data and the presence of anal pathology.

Adolescent↗
PubMed1996

Massive intestinal bleeding in association with Crohn's disease.

Five hundred and one patients with Crohn's disease, presenting to a single surgical unit during a 20-year period, were reviewed by utilizing a computerized audit system. Ten patients were identified with rectal bleeding significant enough to require a blood transfusion to maintain cardiovascular homeostasis. The site of bleeding was correctly identified pre-operatively in only one patient, and at the time of surgery in only four patients. In nine (90%) of the 10 cases, the origin of the bleeding was subsequently found to be colonic. All 10 patients were treated surgically, with seven patients requiring fashioning of a stoma, none of whom had gastro-intestinal continuity subsequently re-established. Recurrent bleeding occurred in a single patient. The early post-operative mortality was 20%. Massive rectal bleeding remains an uncommon complication of Crohn's disease, and still carries significant morbidity and mortality. Pre-operative localization of the site of bleeding is uncommon, making intra-operative identification of the bleeding area difficult.

Adult↗