Talk:Bleeding diathesis

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Physiology of hemostasis Whenever a blood vessel is cut the bleeding usually stops spontaneously after some time by the following mechanisms

1. VASCULAR SPASM  The blood vessels contract as a result of neurological reflexes and local myogenic spasm. The reflexes arise from painful stimuli from the damaged vessel wall leading to spasm of the vessel. The spasm lasts for 20 to 30 minutes.

2. PLATELET PHASE. The platelets come in contact with the collagen fibers in the vessel wall, become irregular and sticky. They liberate ADP thromboxane and serotonin, which in turn activate more platelets. These become sticky and aggregate together to form a loose platelet plug. Nevertheless this plug is able to stop the blood until the clotting mechanisms start operating. In cases when platelets are damaged the prolonged bleeding time takes place. Increased bleeding tendency may be due to purpura. Purpura is characterized by spontaneous bleeding into mucosa, manifesting as petechiae (small pinpoint hemorrhage) or ecchymosis (large superficial hemorrhages). Purpura is often associated with quantitative or qualitative deficiency in platelet. Bleeding time according to Duke is from 2-4 min

3. PLASMA PHASE (CLOTTING). Blood clot develops within a minute or two. Traumatized vessels and platelets liberate activating which initiate the clotting process. In cases preceding history of trauma or injury when plasma clotting factor deficiencies take place muscular hematoma, hemarthrosis (bleeding in joints), bleeding into tissues develop. Blood clotting time according to Burcer – the beginning- 2.5 min The end         -5 min To Lee-White                    5-10 min Among various coagulation factor 8 and 9 deficiencies are most common and are called hemophilia A and B respectively. The classification of the hemorrhagic diseases includes 4 groups of diseases link of hemostasis the disturbances were found in 1.	In the blood conguability and fibrinolysis- coagualopathies 2.	In the thrombosytic link – quantatine (thrombocytopaties) and qualitative (thrombocytopathies) disturbances of the thrombosytes. 3.	In the vascular link – vasopathies the form under which the leading role in the development of bleedings is connected with the systemic damage of the microcircular stream. 4.	With the simultaneous disturbance in different links of the hemostasis system. 5.	The important thing in the diagnostics of the hemorrhagic diseases is considered to be the definition of the type of a bleeding.

There are 5 types of bleeding: 1. The hematomic type is characterized by the deep tense and very painful bleedings into big joints, muscles, subcutaneous and peritoneal fat, under aponeurosis and fasces. They lead to the tissue destruction, formation of severe deforming arthroses, muscle atrophies, contractures sometimes appearance of pathological traumas. Profuse spontaneous post-traumatic and post-operative bleedings which do not appear at once after the trauma but only in several hours. It can be observed while coagulopathies.

2. Petechial and spotty or microcircular type of bleeding appears to be not painful not tense surface bleedings into the skin and mucosal membranes that don’t press the surrounding tissues, petechias, gum nasal and uterus bleedings. Bleedings appear spontaneously or at microtraumas. The colour is different (petechias, ecchimosis of red and yellow or green colour) - polymorphism and polychromism of the rash. This type of the bleeding is conditioned by the process in the endothelium in connection with the disturbance of the angiotrophic function of thrombcytes. The bleedings of this kind can be observed at all the thrombocytopathies.

3. The mixed type (microcircular and hematomic ) of bleeding is characterized by the combination of above mentioned manifestations but the bleedings into joints happen rarely, they don’t lead to the deforming arthroses. This type of Willebrant's disease because in this case the dysfunction of thrombocytes is connected with the lessening of the activity of the antihemophilic globuline. The acquired forms occur while DIV syndrome and anticoagulator hyperdosage.

4. The vasculitis and purpura type combines all the hemorrahages conditioned by the inflammatory processes in the microvessels. The hemorrahages appear on the background of expressed excudative and inflammatory processes. The most widespread disease of this group is the hemorrhagic vasculitis. The hemorrhagic rash on the skin is symmetric, situated on the extremities, body, goes above the skin surface because of the inflammatory processes in the skin. This rash be comes hemorrhagic with consequent pigmentation.

5. The angiomatosis type cam be observed while the constant bleedings from one or two places (from the nose and the lungs).The bleeding occurs from the places where there are angiomas or teleangioectazy).

Diagnostic approach to bleeding disorders

1.	If the child develops petechiae or superficial spontaneous ecchymosis without preceding history of trauma or injury, consider the possibility of bleeding disorders. 2.	Congenital varieties of plasma clotting factor deficiencies manifest early in life, presenting with prolonged bleeding from umbilical cord, bleeding from gums during eruption of teeth, subcutaneous or muscular hematomas. 3.  Positive family history is obtained more often in plasma coagulation factor   deficiencies. 4.	Bleeding defect of purpura usually manifests later in life. 5.	Laboratory investigations. Following laboratory tests are useful in distinguishing bleeding from coagulation defects. Increased bleeding time Platelet count decreased- idiopathic thrombocytopenic purpura, purpura secondary to aplasia, leukemia. One should take history of intake of drugs which can cause thrombocytopenia. Increased clotting time 1. Only protrombin time (PT) prolonged. Suggest Factor 7 deficiency.

2. Only activated partial thromboplastin time (APTT) prolonged. It suggests the deficiency of factors involved in the first stage of coagulation- 8,9,12 and von Willebrands disease. Individual factor deficiency can be identified by factor assays or by mixing studies.

3.	Both PT and APTT prolonged. Suggestive of vitamin K deficiency, severe liver disease and congenital deficiency of factors concerned in second stage of coagulation- factors 5 and 10, fibrinogen deficiency, disseminated intravascular coagulation. IMMUNETHROMBOCYTOPENIC PURPURA (ITP)

Immune thrombocytopenic purpura previously referred to as idiopathic thrombocytopenic purpura, is characterized by petechial hemorrhages, ecchymosis, thrombocytopenia, reduced platelet survival, presence of platelet antibodies and a normal or increased number of megacariocytes in the bone marrow. In most cases the cause is not identifiable.

PATHOGENESIS Thrombocytopenia results from the increased destruction of the antibody coated platelets by the reticuloendothelial system in the spleen. These antibodies are directed against the platelet membrane antigen. The antiplatelet antibodeis are usually of IgG class or IgM  or their combination. When antibodies are bound into the immune complex it leads to the platelets sequestration in the spleen or liver and their half life is diminished. CLASSIFICATION Acute ITP. There is sudden onset of symptoms often associated with severe thrombocytopenia and preceded by viral infections in 50% of the cases. More than 80 % cases resolve spontaneously within 1-2 months. Chronic ITP. Patients have an insidious onset of symptoms and thrombocytopenia is not severe. Viral or other infections often do not precede the initial attack.

Acute and chronic ITP

Features                                             Acute                                     Chronic

Duration                                            4-6 weeks                              >6 months\years

Onset                                                Acute                                        Insidious

Peak age incidence                           2-6 yrs. All ages

Sex predilection                                None                                         F\M-3\1

Antecedent infection                        Common                                   Unusual

Hemorrhagic bullae                          Common in                             Rare (Oral mucosa) Eosinophilia\lymphocytosis              Common                                   Rare

Associated immunogical                   None                                         20%

Spontaneous remission                     80%                                           Uncommon Epidemiology

The peak age of purpura is between 2-8 years. Boys and girls are equally affected in acute ITP. Chronic ITP is more common in girls. Prevalence is not related to any season. Children with HLA B-8 and B-12 are at higher risk of developing ITP.

Clinical Presentation

Easy bruisability and subcutaneous hemorrhages occur spontaneously or following minor trauma. Petechiae may be present all over the skin. Ecchymoses are observed over the anterior surface of the lower limbs and over the bony prominence. Bleeding from the mucosal surfaces is seen in one-third of cases. Bleeding in the joints, tissues, muscles are unusual. Anemia is always proportional to the degree of bleeding. The spleen is often not palpable or the tip of spleen is just palpable. Significant splenomegaly or anemia disproportionate to the bleeding should suggest the diagnosis of secondary purpura rather than of the idiopathic form. Severe manifestations include hematuria, gastrointestinal bleeding, severe epistaxis, menorrhagia in adolescent girls. Intracranial bleed may occur in 1-2 % of children and may prove fatal.

Laboratory investigations

Isolated thrombocytopenia below <100.000mm3 is the only abnormality found in complete blood count. Mean platelet volume is increased. Capillary fragility test is positive. Bleeding time is prolonged while the prothrombin time and the partial thromboplastin time are normal. Platelet antibodies can be demonstrated in 70-90% of children. Bone marrow reveals normal or increased number of megacaryocytes. Bone marrow examination is undertaken to exclude the possibility of leukemia, aplastic anemia, tumor cell infiltration or other causes of thrombocytopenia.

Differential diagnosis

Diagnosis of ITP is essentially a process of exclusion of thrombocytopenia by detailed history, clinical examination and laboratory investigations. Children with aplastic anemia and leukemia have anemia which is out of proportion to the blood loss along with abnormal blood counts. The presence of lymph nodes, hepatosplenomegaly or sternal tenderness also suggests the possibility of leukemia. Intake of drugs such as quinine, heparin, NSAIDS, anticonvulsants, cephalosporin, sulfonamides etc. should be excluded. Presence of giant platelets suggests the possibility of congenital platelets defect. Other uncommon causes which need to be excluded hemolytic uremic syndrome (HUS). Treatment Supportive care includes restriction of physical activities, outdoor games and avoidance of aspirin and related drugs. Intramuscular injections should be avoided during the course of disease. Platelet transfusions may be given in life –threatening situations or prior to surgery in presence of severe thrombocytopenia.

Corticosteroids Corticosteroids inhibit platelet antibody production, prolonged platelet survival and improve vascular stability. Usual dose is 1-2 mg\kg\day of prednisolone for 2-3 weeks followed by decrease doses the next 1-2 weeks. Bleeding manifestation often resolve earlier than the increase in platelet count. Intravenous pulse methylprednisolone (30 mg\kg\day) is more effective in increasing the platelet count to safer level. In cases Chronic ITP corticosteroids are used for longer periods (4-6 months).

Intravenous Immunoglobulin (IV-IgG) IV-IgG increase the platelet count and protect the platelet from antibodies. A total dose of 2g\kg is given. Some children respond within 48 hours. Splenectomy Patients having chronic ITP, uncontrolled bleeding or those not responding to steroids or IV IgG therapy should be considered for splenectomy. Majority of patients (60-85%) achieve remission. Immunosuppressive therapy Immunosuppressive drugs such as cyclosporine, cyclophosphamide, and azathioprine are used either alone or in combination with varying results.

Plasma coagulation factor deficiencies

These can be either hereditary or acquired. Hereditary coagulation factor deficiency is most common in children. Among these hemophilia A and B along with von Willebrands disease accounts for 90-95% of cases. Hemophilia Hemophilia is due to congenital deficiency of plasma coagulation factor 8 (hemophilia A) or factor 9 (hemophilia B). The genes that control the production of the clotting factors VIII and IX are located in the X chromosome. Males (XY) have hemophilia when the gene for clotting factor VIII (Hemophilia A, classical hemophilia) or clotting factor IX (Hemophilia B, Christmas disease) on the single X chromosome is affected. Women (XX) who are carriers generally don't have symptoms of hemophilia because only one X chromosome has a copy of the hemophilia gene. The other gene of the other X chromosome allows for normal production levels of clotting factors VIII or IX. Those women who have only one affected gene are called hemophilia carriers. Not all males with hemophilia have mothers who are carriers. Sometimes a mutation (a genetic change) occurs resulting in hemophilia. Currently, it is not known why this mutation happens. Sons of women who carry the hemophilia gene have a 50 percent chance of inheriting the gene and having hemophilia. Daughters of women who are carriers have a 50 percent chance of also being carriers of hemophilia. In families where only one male is known to have hemophilia; it is usually possible to determine whether the hemophilia gene was passed from a mother who carries the gene or whether a new mutation occurred in the person with hemophilia. Clinical features

Children with mild and moderate disease are asymptomatic and may develop prolonged bleeding following tooth extraction, severe trauma or following surgery. Children with severe hemophilia present with prolonged bleeding, muscle hematoma, and bleeding in joints. Severe mucosal bleeding usually occurs following trauma or tooth extraction. Spontaneous bleeding episodes have also been observed. Excessive bleeding from umbilical cord may be presenting feature in newborns. Prolonged bleeding following circumcisions may be the first symptom. Rarely neonate may develop intracranial bleeding. As the children learn to walk, there are repeated episodes hemarthrosis. Weight bearing joints such as knees, ankles are more often affected than elbow and wrist. Patients often develop painful joint swelling along with restriction of movements and raised temperature of the affected joints. Recurrent hemarthrosis leads to ankylosis, synovial thickening and atrophy of the surrounding muscles (chronic arthropathy). Bleeding in the muscles causes severe pain and disability. Children with retroperitoneal bleeding may present with severe abdominal pain, anemia and even shock. Intracranial bleeding is uncommon.

Laboratory investigations Children have normal bleeding time with prolonged clotting and partial thromboplastin time. The level of Factor 8 or 9 concentrations can be identified in the adsorbed plasma. The normal index is above 45%. Stage of degree is defined according to following indices: 1. The very severe stage - the level of Factors concentration in plasma               below than 2% 2. The moderate  severe stage – from 2-5%. 3. The moderate  stage -5-15%. 4. Latent form  - 15-45%.

Therapy The main principles of management include control and prevention of bleeding, treatment of complications and rehabilitation. Children and parents need to be educated for early detection, benefits of prophylaxis, rehabilitation and prolonged management. These children should receive all immunizations. Replacement therapy is essential for effective control of bleeding and to prevent musculoskeletal deformities. Factor 8 and 9 are present in fresh frozen plasma (FFP). Cryoprecipitate made from single donor contains F8, von Willebrand factor and fibrinogen. FFP and cryoprecipitate are economical. Each unit of FFP contains nearly 200 units of factor 8\9 while one unit of cryoprecipitate contains nearly 100 units of factor 8. One unit of factor 8 raises the factor 8 level by 2%. While one unit of factor 9 raises factor 9 by 1%. The dose of cryoprecipitate is calculated the following way: Weight (kg) •level of the factor (%) ׃ 1.3 Approximately in practice while the small hematomas the 10-20U/kg of cryoprecipitate are given. In case of large and deep hematomas the are prescribed 20-30U/kg even up to 40U/kg. Administration of FFP\cryoprecipitate may be associated with risk of blood transmitted infection such as HIV, hepatitis B, C, and CMV etc. Now, prothrombin complex concentrates are available. These are useful in treatment of factor 9 deficiency.

Hemarthrosis 1.	Administer 25 U/kg of factor 8 every 12 hours for 1 day. 2.	Immobililize the joint for 48 hours. 3.	Aspiration of blood from the joint should not do. 4.	Start ambulation and muscle strengthening exercises to prevent residual orthopedic deformations after the acute stage is over.

Aspirin, indometacin and butalazolidone inhibit the platelets functions and promote gastrointestinal bleeding. These are not used to relieve the pain in patients of hemophilia. However, paracetamol and diazepam may be used safely.

Prophlylactic therapy.

Prophylactic therapy- children have been given 10-20 units per kg of factor 8 twice or thrice a week. Prophylactic are able to lead normal life and even participate in sports. Henoch-Schönlein Purpura Henoch-Schönlein purpura (HSP) is a systemic vasculitis that causes the blood vessels in the skin to become inflamed, causing red spots. When the blood vessels in the skin get inflamed, they can bleed, causing a rash that is called purpura. This rash is typically seen on the lower legs or arms. HSP occurs more often in children than in adults, and many cases follow an upper respiratory tract infection. Half of affected children are under age of five, although kidney involvement is more likely to be severe in older children. Symptoms occur over a period of days to several weeks: skin rash, joint aches and pains, usually in knees and ankles, occasional swelling, abdominal pain and renal disease manifesting mostly as hematuria (blood in urine), proteinuria (abnormal excretion of proteins in urine), edema (swelling) or alteration in the volume of urine. The hematuria may be noticed as red or tea-colored urine. Gastrointestinal symptoms are present in the majority of patients including abdominal pain that is frequently associated with vomiting. The pain typically develops within eight days of the appearance of the rash. Bleeding of the gastrointestinal tract presenting with black or bright red color in stools is seen in these patients. In that way the several clinical groups are distinguished: 1. Simple (skin) form (damage only skin- presence of macules, papules, petechias). 2. Skin –articular form (arthritis, arthralgia and are added to skin form). 3. Abdominal form (it needs the urgent care). 4. Renal form 5. Combined form (combination of above-mentioned types of HSD) The last tree types have severe onset due to gastrointestinal bleeding, hematuria, Disturbances of kidneys function even development acute renal insufficiency. Laboratory investigations Post hemorrhagic anemia as a rule in mild form, increases number of thrombocytes in initial stage, neutrophilosis, shortening of blood clotting time and normal bleeding time, are observed in blood analysis. Laboratory features of hypercoagulation are common. Treatment. Anti-inflammatory medicines – same nonsteroid preparations (NSAIDS), corticosteroids, dipyridamole, heparin/warfarin. Plasmapheresis are used in patients with severe disease.

Reference by Dr. Avadh Sahi

British guideline for rare coagulation disorders
10.1111/bjh.13058 - excludes vWD and haemophilia A & B but covers everything else. JFW &#124; T@lk  08:42, 13 August 2014 (UTC)