Internal bleeding: symptoms and causes

Internal hemorrhage is a hemorrhage that can take place inside tissues, organs, or body cavities, including the head, chest, and abdomen.

Internal bleeding occurs when blood leaks from an artery or vein from the circulatory system and accumulates inside the body.

There are two other types of hemorrhages:

• The external bleeding, which consists in the fact that the blood from the body penetrates to the outside, that is, if it is a skin injury;
• The exteriorized bleeding that occurs when blood leaks from the body through natural openings, for example, from the nose (epistaxis), mouth (hematemesis), vagina (metrorrhagia), etc.

Blood loss may be minor, but can also lead to death in severe cases.

Classification of bleeding

Bleeding properties Severe

• 1500 ml within a few hours
• Hct < 20 %
• Hb < 6 g/dl
• Shock

Moderate

• 1000 ml
• Hct 20-30 %
• Hb = 6-8 g/dl
• FC > 100 rpm
• Possible shock

Mild

• < 1000 ml
• Hct > 30 %
• Hb > 8 g/dl
• No shock

HCT = hematocrit, Hb = hemoglobin, FC = heart rate

How internal bleeding develops (pathophysiology)

There are four main mechanisms that allow hemostasis (process of bleeding interruption):

1. Vasoconstriction, reduces blood loss.
2. Formation of platelet clots: some blood clotting factors lead to the adhesion of platelets on the walls of blood vessels and with other platelets.
3. The coagulation process – fibrinogen is converted into fibrin. Networks of this substance are formed, which trap platelets and red blood cells (coagulation).
4. The fibrinolytic process – the fibrin is removed and the endothelial cells can repair the blood vessel.

Hemostasis may not be effective due to:

• A change in the blood vessel that interferes with vasoconstriction,
• A change in platelets, for example thrombocytopenia (decreased platelet count) or thrombocytopathy (change in function),
• A lack of clotting factors.

Change of blood vessels and endothelium

• With hemorrhagic telangiectasia, blood vessels remain dilated.
• Some toxins or immune complexes can reduce the ability of blood vessels to contract,
• scurvy (vitamin C deficiency), which causes reduced vasoconstriction,
• Endothelin deficiency, – leads to vasodilation
• Hyperelastosis – this is an increase in elastic fibers that reduce the ability to contract,
• Amyloidosis – a deposit of the substance amyloid, which makes the vessel stiffer so that it cannot contract.
• Impaired endothelial function – in von Willebrand disease, the reduction in clotting factors causes less adhesion of platelets to the endothelium.
• Increased production of prostacyclin, which causes vasodilation, for example, in renal insufficiency.

Changes in platelets

Thrombocytopathy is a platelet disorder that causes reduced platelet adhesion.

• In the case of collagen disease, the receptor (a protein that can be used to accept or bind something) for collagen is missing.
• Absence of the receptor for von Willebrand factor (coagulation factor).
• Uremia (terminal stage in renal insufficiency) and liver failure. There are waste products and toxins in the blood because the kidney can’t excrete them or the liver can’t metabolize them. These disrupt the mechanism of platelet adhesion.
• Macroglobulinemia and myeloma – there are abnormal immunoglobulins in the bloodstream that interfere with platelet adhesion to the endothelium.
• Myeloproliferative syndrome – this is a change in the megakaryocyte (a cell from which platelets emerge) that causes a change in platelets.
• Acquired von Willebrand disease – substances or antibodies attack von Willebrand factor.

Changes in the platelet aggregation process

• Glanzmann’s thrombastenia – a disease characterized by fibrinogen receptor deficiency, preventing platelet aggregation.
• Essential athrombia – there is a deficiency of α-actinin, which serves to change the shape of the platelet.
• Congenital afibrinogenemia, in which the body does not produce fibrinogen, and hypofibrinogenemia.

Some enzymes intervene in coagulation to form thromboxane A2:

1. phospholipase,
2. cyclooxygenase,
3. Thromboxane synthase.

A deficiency of these enzymes can lead to delayed blood clotting.

Thrombocytopenia

Thrombocytopenia can be caused by:

• A reduced production in the bone marrow,
• An increase in platelet destruction,
• Changes in the distribution of platelets in the circulation – the spleen is a blood reservoir. With an enlargement of the spleen, the concentration of platelets in the spleen increases.

Decreased platelet production

• thrombopoietin deficiency,
• alteration of stem cells,
• entry of toxins into the bone marrow,
• side effects of chemotherapy and radiotherapy,
• neoplasia of the bone marrow,
• Vitamin deficiencies, for example vitamin B12 and folic acid – in this case, abnormal platelets and red blood cells are formed, which die in the bone marrow before entering the bloodstream.

Increased destruction of platelets

• Purpura – viral disease, autoimmune or caused by drugs, which leads to the destruction of platelets.
• Medications – many medications can cause platelet counts to drop, especially:
  • sulfonamides,
  • Heparin
  • Aspirin.
• CID (or disseminated intravascular coagulation disorder), in this case, there is the formation of small clots, diffusely distributed in the smallest blood vessels, in which platelets and clotting factors are included.

Changes in coagulation factors

• Hemophilia – a disease characterized by a lack of clotting factors.
• Lack of vitamin K, which is used to produce coagulation factors.
• Hepatic insufficiency – the liver produces clotting factors.
• Antibodies that inactivate coagulation factors.

Causes of internal bleeding

Blunt trauma

Most people know that a fall from a great height or a car accident can cause a contusion or trauma to the body.

This is the most common cause in children.

The body does not have to be externally injured, but there may be a bruise of the internal organs, which leads to injuries to blood vessels (especially capillaries) and bleeding.

If the accident occurs in the area of the back or flanks (where the kidneys are located), it can cause retroperitoneal hemorrhage.

The eye can be compressed in the eye socket during a punch or by a ball.

Deceleration trauma

Deceleration trauma can lead to displacement of the internal body organs.

Fractures

Bleeding may be caused by a bone fracture. There are many blood vessels inside the bones, so a very large bruise can occur.

Pregnancy

Bleeding in pregnancy is never normal, even if it is not uncommon in the first trimester. It can be the sign of a spontaneous abortion.

In the first weeks of pregnancy, vaginal bleeding is the potential sign of ovarian pregnancy (when the fertilized egg remains in the fallopian tube instead of implanting in the uterus).

Spontaneous bleeding

Internal bleeding can occur for no reason if the patient:

1. taking anticoagulant drugs,
2. Has a disease such as leukemia.

Side effect of medication and alcohol

Internal bleeding can occur as a side effect of medications, especially when it comes to medications such as nonsteroidal anti-inflammatory drugs (such as ibuprofen), aspirin, or alcohol.

After childbirth

Bleeding may occur during childbirth. In the case of a caesarean delivery, the risk is greater, especially if the woman has already had a previous caesarean section.

Uterine bleeding

Causes of gastric and intestinal bleeding

1. Mechanical. — external or internal trauma.
   The bleeding may be caused by:
   1. One blow,
   2. Incorrect use of an endoscope during gastric lavage,
   3. ingestion of food with a hard and rough surface,
   4. Drinking corrosive substances such as acids or alkalis
2. Surgery
   Bleeding in the stomach may occur after opening the abdominal cavity, in which the abdominal mesh (part of the peritoneum) has been injured.
   The bleeding may also occur after minimally invasive surgery in laparoscopy.
3. Illness
   Bleeding of the esophagus may be caused by:

• Esophagitis and gastroesophageal reflux.
• Heartburn that rises in the esophagus can lead to inflammation of the esophagus (esophagitis), which can provoke hemorrhage.
• Varicose veins. Highly dilated veins usually occur in the lower part of the esophagus or in the upper stomach area.
• These veins are called varicose veins. They are veins that can rupture and lead to heavy bleeding.
• Cirrhosis of the liver is the most common cause of esophageal varices.
• Mallory-Weiss syndrome is a tear in the esophageal wall that can occur mainly due to prolonged vomiting. However, the syndrome can also be caused by other causes of the abdominal increase in pressure, such as:

1. Cough
2. chronic hiccups,
3. Parturition.

Gastric bleeding can be caused by:

1. Gastritis. Causes of stomach ulcer or inflammation include:
   1. Alcohol
   2. medications including NSAIDs (nonsteroidal anti-inflammatories), aspirin, ibuprofen (brufen) or naproxen, etc.,
   3. Problems of anxiety, stress and guilt.
2. Peptic and duodenal ulcers.
   The stomach ulcer can spread and involve a blood vessel, causing bleeding.
   In addition to medication, there are other causes of a stomach ulcer:
   1. An infection caused by a bacterium called Helicobacter pylori,
   2. Anorexia.
3. stomach tumor;

Bleeding from the lower digestive tract (colon, rectum and anus) can be caused by:

• Hemorrhoids. This is probably the most common cause of visible blood from the lower digestive tract, especially if it is red and light.
• Hemorrhoids are dilated veins in the area that can rupture.
• The patient sees fresh traces of blood on the chair or on the toilet paper.
• rhagades, injuries in the mucosa can cause bleeding. These wounds are very painful.
• Colon polyps. These are protrusions that can form in the large intestine. Usually these are benign structures, but they can cause bleeding.
• Rectal colon tumor.
• Intestinal infections. Inflammation and bloody diarrhea can be the result of intestinal infections.
• ulcerative colitis; This condition can lead to inflammation and heavy bleeding from small ulcerations. It is a cause of blood in the stool.
• Crohn’s disease. This chronic condition is caused by inflammation in the digestive system and, in rare cases, can lead to rectal bleeding in the colon and small intestine.
• Diverticulitis. It is the inflammation of diverticula – these are indentations of the colon mucosa.
• Malformation of blood vessels. With age, abnormalities of the blood vessels in the colon can develop, which can lead to bleeding.
• Angiodysplasias – they are common in the elderly and often have a star shape. They are typical of the ascending colon and lead to blood loss from the intestine and red blood in the stool.

Symptoms of internal hemorrhages in the digestive system

The signs of gastric and intestinal bleeding depend on their localization and severity.

Signs of bleeding in the upper digestive tract include:

1. Fresh red blood in vomit,
2. Coffee-like vomit,
3. Black chair,
4. stool with dark blood,

Signs of bleeding in the lower digestive tract: dark or red blood in the stool.

With acute and sudden bleeding, the symptoms may be:

1. weakness – because blood transports oxygen and nutrients, so blood loss causes a lower supply of cells,
2. dizziness or fainting – if the bleeding is heavy and causes a significant drop in blood pressure or hypovolemic shock (due to lack of blood),
3. shortness of breath – especially with chest bleeding,
4. abdominal pain and abdominal cramps (in case of bleeding of the digestive system),
5. Diarrhoea
6. Paleness.

How to recognize bleeding of the digestive tract?

If blood leaks from the rectum or lower colon, the blood is bright red and mixed with stool.

The stool may be mixed with darker blood if the bleeding occurs in the upper colon or at the end of the small intestine.

With bleeding in the esophagus, stomach or duodenum, the stool is:

• Black
• Tarty,
• Malodorous.

Vomit may look bright red or coffee grounds-like if bleeding occurs in:

1. Esophagus
2. Stomach
3. Duodenum.

If the bleeding is occult or hidden, then it is possible that no color change of the stool is noticed.

For diagnosis, the most important thing is the clinical examination, as well as information about the colors of stool, urine and vomit.

The doctor prescribes:

1. blood test to determine the cause of the bleeding,
2. A gastroscopy to assess the condition of the stomach and duodenum,
3. A colonoscopy to examine the colon and rectum.

With sudden massive hemorrhage, a person may feel:

1. Weakness
2. Fatigue
3. Shortness
4. Vertigo
5. abdominal cramps,
6. Stomach ache
7. shock (sudden and rapid drop in blood pressure),
8. facial pallor,
9. Diarrhoea.

Well, what time does this occur?

A sudden bleeding causes the first symptoms after just a few minutes. If it occurs slowly and persists for a long time, the symptoms appear gradually:

1. Fatigue
2. Apathy
3. Shortness
4. Anaemia.

Anemia is a condition in which there is a reduction in hemoglobin.

Caution: Dietary supplements containing iron, acetylsalicylic acid (contained in aspirin) and some foods, such as beetroot, can cause red or black stools.

Uterine bleeding

A uterine hemorrhage is a loss of blood from the blood vessels inside the uterus.

This bleeding is usually not related to the menstrual cycle, except in the case of missing ovulation, is considered abnormal and is a medical emergency.

Neoplasia, pregnancy, trauma and absence of ovulation represent the majority of abnormal cases of bleeding in the uterus.

Chronic and infectious diseases can cause uterine bleeding.

In most cases, uterine bleeding can last from two to seven days.

Bleeding related to pregnancy includes:

1. postpartum hemorrhage,
2. bleeding after a spontaneous abortion,
3. Abdominal pregnancy.

According to a study by Jolma CD et al. (Liaquat National Medical College, 402, Al Jannat Plaza, M.A. Jinnah road Saed manzil, Karachis, Pakistan), postpartum hemorrhage is defined as loss of at least 500 ml of blood.

The main causes of postpartum hemorrhage are:

1. Contractile weakness of the uterus as the most common cause. After the expulsion of the placenta, the muscle contraction of the uterus compresses the blood vessels in the area where the placenta was attached. If the contraction is weak, the blood emerges freely from the vessels and bleeding occurs.
2. tear of cervix and vagina,
3. placenta accreta or impaired adhesion of the placenta or a part that does not detach after birth,
4. Placenta ritenuta (remains inside the uterine cavity after birth or detachment).

Ectopic pregnancy and spontaneous miscarriage can cause:

• bleeding,
• abdominal pain,
• Severe convulsions.

Blood in the urine may be caused by internal hemorrhage from the urinary tract, kidney and bladder.

Often a bladder infection is associated with blood admixtures in the urine, but other causes must be considered based on the patient’s symptoms, such as age and medical history, especially in men who have undergone prostate surgery.

Men and women who have received radiation therapy may develop inflammation in the bladder mucosa, causing heavy bleeding.

Among the causes of blood in the urine caused by internal hemorrhages is pelvic fracture.

What is cerebral hemorrhage?

Cerebral hemorrhage is a hemorrhage inside or outside the brain.

Causes of cerebral hemorrhage include:

1. Hypertension
2. Aneurysm
3. Anticoagulants
4. Traumas.

Many people with cerebral hemorrhage develop the symptoms of stroke:

• loss of strength on one side of the body,
• speech disorders,
• numbness or loss of sensitivity,
• difficulties in carrying out day-to-day activities,
• Gait disturbances.

About 10% of strokes are caused by cerebral hemorrhage.

Muscle bleeding

After an accident, bleeding can also occur into the deepest areas of the muscles.

The consequence is the formation of a painful hematoma.

In rare cases, compartment syndrome may occur.

During hemorrhage, bleeding causes swelling and an increase in pressure inside the muscular compartment, which exceeds the patient’s arterial pressure.

As a result, the blood can no longer be pumped into the muscle cells.

The symptoms of compartment syndrome are:

1. knocking pain,
2. difficulty with joint movements,
3. Loss of sensitivity.

As a rule, this can be seen in injuries to the leg or arm (especially the forearm), which can be caused by a fracture:

• of the shin,
• of the fibula,
• The spoke,
• The Elle.

Hemorrhage can also occur in joints (hemarthrosis), causing pain and restriction of range of motion.

This is often seen in patients taking anticoagulant drugs.

What to do? First aid for internal bleeding

You should lie down the patient slowly and call the ambulance.

In case of bleeding from the ear, it is necessary to lay the patient on the side on which he is bleeding. If, on the other hand, blood leaks from the nose, you should bend your head forward.

How long does the disease last? The prognosis for a patient with internal bleeding

One can not stop bleeding without knowing the severity of the injury to blood vessels and the patient’s condition.

• High blood pressure: symptoms, causes and values
• Hard stools and feces: causes and symptoms
• Cerebral hemorrhage: symptoms and consequences, subarachnoid