Hemorrhagic discharge. Consequences of hemorrhagic disease. Main symptoms of internal bleeding

Hemorrhagic cerebral stroke: types, symptoms, diagnosis, treatment, risk factors

A hemorrhagic cerebral stroke is a sudden disruption of cerebral circulation with the formation of a hematoma or saturation of nerve tissue with blood. Damage to the brain substance leads to significant neurological disorders up to total loss motor and sensory function, as well as disturbances in swallowing, speech, and breathing. Stroke has high probability death, and the majority of surviving patients remain permanently disabled.

Unfortunately, the word “stroke” is familiar, if not to everyone, then to most of us. Increasingly, this diagnosis can be found among people of working age. This condition means a violation of blood circulation in the brain due to various reasons, as a result of which either necrosis occurs - then they talk about an ischemic stroke (cerebral infarction), or bleeding into the brain tissue - then they talk about a stroke hemorrhagic type, which will be discussed in this article.

According to statistics, Mortality in the first month from the onset of the disease reaches 80% even in countries with high level development of medicine. Survival rates after hemorrhagic stroke are low and significantly lower than for cerebral infarctions. During the first year, 60-80% of patients die, and more than half of those who survive remain permanently disabled.

Causes and risk factors for cerebral hemorrhages

The development mechanisms and etiology of this insidious disease are well studied and described in textbooks on neurology, but the difficulties of diagnosis, especially in prehospital stage, still exist today. So what are the main causes of hemorrhagic stroke? Today, the most common of them are:

• Vascular and.
• Among more rare causes can be called:
• Inflammatory and dystrophic changes in vascular walls (amyloid angiopathy);
• Diseases accompanied by blood clotting disorders (,);
• Purpose and fibrinolytic agents (aspirin, heparin, warfarin);
• Liver cirrhosis, in which the synthesis of blood coagulation factors in the liver is impaired, the number of platelets decreases, which inevitably leads to the development of bleeding and hemorrhages, including in the brain;
• Hemorrhages in a brain tumor.

It is worth noting that the word stroke is more correctly used in cases where the causative factor is arterial hypertension or there are vascular anomalies, while the second group of causes causes secondary hemorrhages and the term “stroke” is not always used in such cases.

In addition to the above factors that create the morphological substrate for the disease (damage vascular wall), exist and predisposing like this:

1. Smoking;
2. Alcohol abuse;
3. Addiction;
4. Obesity and lipid disorders;
5. Age over 50 years;
6. Unfavorable family history (hereditary factor).

Speaking about hemorrhages in the brain, one cannot fail to mention the vascular wall. As a rule, the presence of lipid plaques leads to the closure of the lumen of blood vessels with the development of necrosis - cerebral infarction, or ischemic stroke. At the same time, damage to the vascular wall with its thinning, atheromatosis, ulcerations in conditions of high blood pressure creates all the conditions for subsequent rupture and hemorrhage.

Video: non-standard causes of stroke

Mechanisms of development of hemorrhagic stroke

As you know, most of the world's population suffers after 40-50 years. Many simply do not pay attention to alarming ones or do not even know that the disease already exists and is progressing without giving any manifestations. In the same time, are already happening in the body irreversible changes, which primarily concern arterial vessels. The brain in this case is the so-called “target organ” along with the kidneys, retina, heart, and adrenal glands.

In arteries and arterioles under the influence high blood pressure thickening of their muscle layer occurs, impregnation with plasma proteins, fibrinoid changes up to necrosis of areas of the vascular wall. Over time, these vessels become fragile, microaneurysms (local dilations) appear, which, with sudden increases in blood pressure () have high probability ruptures with blood penetration into the brain tissue. In addition, damage to the vascular walls is often accompanied by an increase in their permeability, as a result of which blood comes out through them (diapedetic bleeding) and, as it were, permeates the nervous tissue, penetrating diffusely between cells and fibers.

If arterial hypertension leads to acute hemorrhagic stroke, usually in older people, then changes such as aneurysms or vascular malformations are the fate of young people and even children and adolescents.

photo: rupture of a saccular aneurysm during a hemorrhagic stroke

is a local expansion of the lumen of the vessel, usually of a congenital nature, having an irregular wall structure.

- This birth defects in the development of blood vessels with the formation of tangles, weaves, pathological connections between the arterial and venous beds without the presence of a capillary network, in which blood is discharged directly from the arteries into the veins, which is accompanied by a disruption in the supply of tissue with oxygen and nutrients.

Vascular aneurysms and malformations often do not provide any clinical manifestations until they rupture and hemorrhage. This is their “cunning”, because patients or their relatives do not even suspect the presence of such a pathology.

serious cerebral vascular malformation that can lead to stroke at

This problem is especially acute in children and adolescents, when sudden brain damage can leave lasting consequences for the rest of their lives or even lead to death.

In the case of hypertension or vascular abnormalities, it is more important than ever to adhere to healthy image life. Smoking, obesity, and alcohol abuse can create an unfavorable background that will significantly accelerate the progression of the disease itself, as well as increase the likelihood of its severe course and death.

Main types of hemorrhagic strokes and their classification

Depending on the location and characteristics of structural changes in the brain, several types of hemorrhagic strokes are distinguished. Highlight:

• Subarachnoid hemorrhage;
• Parenchymal hemorrhage;
• Intraventricular hemorrhage;
• Sub- and epidural hemorrhage (non-traumatic).

is an accumulation of blood under the soft tissue meninges, consisting of blood vessels and covering the outside of the brain. Typically, this type of stroke is caused by aneurysms and vascular malformations. When a vessel ruptures, blood spreads over the surface of the brain, and sometimes involves its tissue in pathological process- then they talk about subarachnoid-parenchymal hemorrhage.

Parenchymal hemorrhage– the most common type of stroke, in which blood enters directly into the brain. Depending on the nature of the damage, there are two types of parenchymal hemorrhages:

1. Hematoma;
2. Hemorrhagic impregnation.

Hematoma It is a cavity filled with spilled blood. With this type of stroke, the death of cellular elements in the affected area occurs, which causes severe neurological deficits with severe clinical symptoms and high risk of death. Nervous tissue is highly specialized and very complex functionally and structurally, and neurons are not able to reproduce by fission, so such damage does not have a chance of a favorable outcome.

At hemorrhagic impregnation blood penetrates between the elements of the nervous tissue, but such massive destruction and death of neurons as with a hematoma does not occur, therefore the prognosis is much more favorable. As a rule, the main cause of this type of stroke is an increase in vascular permeability with erythrocyte diapedesis during arterial hypertension, thrombocytopenia, treatment with anticoagulants.

Intraventricular hemorrhages are possible with ruptures of the vascular plexuses located in them, but more often they are of a secondary nature. In other words, blood enters ventricular system brain in the presence of large hemispheric hematomas. In this case, obstruction (closure) of the cerebrospinal fluid ducts with blood occurs, hydrocephalus develops due to impaired outflow cerebrospinal fluid from the cranial cavity, cerebral edema rapidly increases. Chances of surviving in such a situation minimal. As a rule, such patients die in the first 1-2 days from the moment blood enters the ventricles of the brain.

Sub- and epidural hemorrhages, although they relate to strokes, as a rule, they are traumatic in nature and are the province of neurosurgery.

In addition to the listed types of strokes, there are also their various options depending on location lesion. So, they distinguish:

• Lobar hemorrhages located within one lobe of the brain;
• Deep strokes affecting the subcortical nuclei, deep sections brain, internal capsule;
• Hemorrhagic stroke of the cerebellum;
• Brainstem hemorrhagic stroke.

When talking about an extensive hemorrhagic stroke, we usually mean damage to several parts of the brain or several of its lobes at the same time. This condition is accompanied by damage to a significant part of the parenchyma, rapid development of edema and, as a rule, is incompatible with life.

This refers to small foci of damage to brain tissue that occur against the background of vasospasm due to arterial hypertension and diabetes mellitus. Clinical signs in the form of neurological symptoms most often disappear within 24 hours of their onset. It is important to start treatment as early as possible, preferably in the first 6 hours. The relatively mild course and the absence of irreversible changes should not ignore this condition, which indicates that changes in the vessels of the brain are already pronounced, and the next stage may be the development of a major stroke.

In accordance with the international classification, acute cerebrovascular diseases belong to the group of cerebrovascular diseases included in class IX (includes all diseases of the circulatory system), and are designated by the letter I (lat.). Hemorrhagic stroke according to ICD-10 is coded in category I61, where an additional number after the dot indicates its location, for example, I 61.3 - brainstem intracerebral hemorrhage.

Despite its widespread use, the word “stroke” cannot be used in diagnosis. Thus, it is necessary to indicate its specific type: hematoma, hemorrhagic impregnation or infarction, as well as the location of the lesion.

Due to the high social significance associated with significant mortality and disability for the majority of surviving patients, the diagnosis of cerebral hemorrhage always sounds under the heading of the underlying disease, although in fact it is a complication, in particular, of arterial hypertension.

Video: causes and types of strokes

Clinical manifestations of cerebral hemorrhages

The signs of a hemorrhagic stroke are so varied and even complex that sometimes not every doctor can see them, but a neurologist can make this diagnosis without difficulty. Such a dangerous condition can find a patient anywhere: on the street, in public transport and even on vacation at sea. It is important that at this moment there are, if not specialists, then at least people nearby who are ready to call a doctor or an ambulance, as well as provide first aid and participate in transporting the patient.

The clinical picture of hemorrhagic stroke is determined, first of all, by the location of the lesion and its size. Depending on which brain structures are damaged, specific signs of a violation of one or another of its functions will appear. As a rule, the motor and sensory spheres and speech are most often affected when the hemispheres are damaged. When hemorrhage is localized in the brain stem, damage to vital respiratory and vasomotor centers is possible with a high risk of rapid death.

infographics: AiF

Depending on the time from the onset of the disease and clinical manifestations, we can distinguish following periods hemorrhagic stroke:

1. Acute period;
2. Recovery period;
3. Period of residual effects.

In the acute period cerebral symptoms associated with increased pressure in the cranial cavity due to hemorrhage predominate. It lasts up to a week and is accompanied by the accumulation of blood with damage to the nervous tissue up to necrosis. The most dangerous thing in the acute phase is the rapid development of cerebral edema with dislocation of its structures and herniation of the trunk, which will inevitably lead to death.

Recovery period begins at 2-4 weeks, when reparative processes begin in the brain, aimed at removing blood and restoring the structure of the parenchyma due to the proliferation of neuroglial cells. This period can last several months.

Period of residual effects continues for the rest of your life. With adequate and timely therapeutic and rehabilitation activities sometimes it is possible to restore quite well many body functions, speech and even ability to work, and Patients live for more than one year after a stroke.

The disease often occurs suddenly, during the day, when blood pressure rises ( hypertensive crisis), with strong physical activity or emotional stress. A person suddenly loses consciousness, falls, appears vegetative manifestations in the form of sweating, changes in body temperature, redness of the face or, less commonly, pallor. In some patients, breathing is impaired, tachycardia appears, or, possibly, rapid development of coma.

Shallow epidural and subdural hematomas (pictured) may be accompanied predominantly by the first group of symptoms

Symptoms of hemorrhagic stroke can be divided into two groups.

General cerebral symptoms

General cerebral symptoms due to increased intracranial pressure due to the accumulation of blood in the brain. The greater the volume of hemorrhage and the speed of its development, the more pronounced they will be. General cerebral manifestations of hemorrhagic strokes include:

1. Severe headache;
2. Vomiting;
3. Impaired consciousness;
4. Convulsive syndrome.

Focal neurological manifestations

Focal neurological symptoms associated with damage to a specific department nervous system. Yes, when hemispheric hemorrhages, most common, characteristic symptoms will be:

1. Hemiparesis or hemiplegia on the side opposite the lesion (complete or partial impairment of movement in the arm and leg), decreased muscle tone and tendon reflexes;
2. Hemihypesthesia (impaired sensitivity on the opposite side);
3. Gaze paresis ( eyeballs will be turned towards the hemorrhage), mydriasis (dilation of the pupil) on the affected side, drooping of the corner of the mouth and smoothness of the nasolabial triangle;
4. Speech impairment due to damage to the dominant hemisphere (left in right-handed people);
5. The appearance of pathological reflexes.

• So, with a hemorrhagic stroke on the left side of the brain, the main symptoms will be expressed on the right, and in right-handed people there will also be a speech disorder. If the right side is affected, the opposite is true, but speech will be impaired in left-handed people, which is due to the peculiar location of the speech center in the brain.
• In case of defeat cerebellum characteristic features will be headache in the back of the head, vomiting, severe dizziness, impaired walking, inability to stand, change in speech. With large cerebellar hemorrhages, edema quickly develops and herniation into the foramen magnum, which leads to death.
• With massive hemorrhages in the hemispheres, it often occurs breakthrough of blood in ventricles of the brain. This condition is accompanied by a sharp disturbance of consciousness, the development of coma and poses an immediate threat to life.
• Subarachnoid hemorrhage accompanied by severe headache and other cerebral symptoms, as well as the development of coma.
• Brain stem stroke is a very dangerous condition, since vital nerve centers, as well as nuclei, are located in this section cranial nerves. With hemorrhage into the trunk, in addition to the development of bilateral paralysis, impaired sensitivity and swallowing, a sudden loss of consciousness with the rapid development of coma, dysfunction of the respiratory and cardiovascular systems due to damage to the respiratory and vasomotor centers is possible. Such severe cases the probability of death reaches 80-90%.

Unfortunately, the prognosis in case of coma after a hemorrhagic stroke is disappointing. Coma occurs especially often with brainstem, massive hemispheric and cerebellar hemorrhage. Despite intensive therapy, such patients die, as a rule, in the acute period of the disease.

Video: signs of stroke

Diagnostic methods

If a cerebral hemorrhage is suspected, it is necessary to carefully question the patient's complaints if the ability to speak meaningfully is preserved. If possible, even through relatives, find out whether the patient has previous arterial hypertension and the characteristics of the development of the disease. As a rule, the main neurological defects are noticeable even to a layman. So, it is enough to talk to the patient, ask him to smile or stick out his tongue to suspect brain damage. Inability to walk, impaired consciousness, speech, and sudden development similar symptoms point to acute disorder blood circulation in the brain.

In an inpatient setting, hemorrhagic stroke is diagnosed through a thorough neurological examination by a medical specialist. Main instrumental method is currently considered to be affordable and very in an informative way diagnostics CT scan can determine the location and size of the lesion.

For small lesions and the presence of vascular malformations, it is possible to use, however, this method is expensive and not always available. In cases of subarachnoid hemorrhages, a study of the cerebrospinal fluid may be informative. lumbar puncture when the detection of red blood cells in the cerebrospinal fluid will be a reliable diagnostic criterion.

For the diagnosis of subarachnoid hemorrhages and, especially, vascular aneurysms and malformations, a highly informative diagnostic method can be angiography. With this research method, it is possible to determine the nature of blood flow in the affected parts of the vascular bed, the presence of anomalies in vascular development by introducing radiocontrast agents. In addition, angiography data will be very useful for subsequent surgical treatment aneurysm.

Differential diagnosis for strokes

In the differential diagnosis of hemorrhagic stroke, it is necessary to distinguish it from brain tumors with secondary hemorrhage, abscesses, cerebral infarctions, epilepsy, traumatic injuries and even hysteria, especially in young women after severe stress. In such cases, in addition to the history, examination and neurological examination, CT and MRI, electroencephalography, and skull radiography come to the rescue.

The question often arises: did an ischemic or hemorrhagic stroke develop in this case? For differential diagnosis you need to know the difference from hemorrhagic. Thus, cerebral hemorrhages are less common, but their mortality rate is much higher; they occur suddenly, during the day, more often in young people, while cerebral infarctions can be accompanied by a period of precursors and occur more often at night or in the morning, in the midst of complete rest. In addition, with hemorrhages in the brain, an accumulation of blood (hematoma) forms, and with heart attacks, ischemia and necrosis will be observed, that is, bleeding and, as a result, cell death.

Complications and consequences of cerebral hemorrhages

Complications of hemorrhagic stroke can occur both in the acute period and for a long time after the onset of hemorrhage. Among the most dangerous are:

• Breakthrough of blood into the ventricular system;
• Increased cerebral edema;
• Development of occlusive hydrocephalus;
• Impairment of systemic hemodynamics and external respiration function, especially with damage to the brain stem.

The listed complications appear more often in the acute period and lead to the death of patients.

Another group of complications is associated with dysfunction of the pelvic organs, heart, prolonged lying position and weakening of the body's defense reactions. Among them, the most characteristic are:

1. Congestive pneumonia;
2. Urinary tract infections;
3. Sepsis;
4. Bedsores;
5. in the veins of the leg with a risk of developing;
6. Cardiac decompensation.

Currently, the most common reasons The death of patients with hemorrhages in the brain is its swelling, dislocation of structures (displacement relative to each other) and herniation of the brain stem into the foramen magnum. In the later period, infectious and inflammatory complications, in particular pneumonia, are most common.

Approaches to the treatment of hemorrhagic stroke

If you suspect a cerebral hemorrhage, you should call a doctor or ambulance as soon as possible. Under no circumstances should the patient stand up, walk, or move with the help of relatives. Treatment of hemorrhagic stroke should begin as soon as possible. early dates. When carrying out the necessary activities in the first 6 hours after the onset of the attack the likelihood of a favorable outcome increases significantly.

infographics: AiF

Treatment of cerebral hemorrhages should be carried out only in specialized clinics, and in the first week it is advisable to place the patient in the intensive care unit under permanent medical supervision. Subsequently, if the course is favorable, the patient is transferred to a specialized neurological or department for patients with vascular pathology of the brain. It is important that the hospital has the opportunity to conduct round-the-clock diagnostic procedures such as CT and MRI, as well as the possibility of emergency neuro surgical intervention.

First aid for a hemorrhagic stroke will be provided by the ambulance team at the pre-hospital stage and on the way to the hospital. It includes:

• Transporting the patient in a lying position with the head end elevated;
• Normalization of blood pressure by administering antihypertensive drugs (clonidine, dibazol, enalapril);
• Combating cerebral edema with osmotic diuretics (mannitol);
• The use of drugs aimed at stopping bleeding (etamzilate);
• Administration of anticonvulsants if indicated, sedative therapy (Relanium);
• Maintaining, if necessary, the function of external respiration and cardiac activity.

Further treatment of hemorrhagic stroke in a hospital setting can be conservative and surgical.

Stroke surgery

Surgical treatment carried out in the neurosurgery department, usually in the first three days from the onset of the disease. Indications for surgery for hemorrhagic stroke are:

1. Large hemispheric hematomas;
2. Breakthrough of blood into the ventricles of the brain;
3. Aneurysm rupture during growth.

Removing blood from the hematoma is aimed at decompression, that is, reducing pressure in the cranial cavity and on the surrounding brain tissue, which significantly improves the prognosis and also helps save the patient’s life.

Non-surgical treatment

Conservative treatment cerebral hemorrhages involves basic and specific neuroprotective and reparative therapy with the prescription of drugs from various pharmacological groups.

Basic therapy for strokes includes:

• Maintaining adequate lung function, if necessary, tracheal intubation and artificial ventilation;
• Normalization of blood pressure (labetalol, enalapril for hypertensive patients, infusion therapy, dopamine for hypotension), correction of heart function for arrhythmias;
• Normalization of water-salt and biochemical balance (infusion therapy, prescription of diuretics - Lasix);
• Prescription of antipyretic drugs for hyperthermia (paracetamol, magnesium sulfate);
• Reduction and prevention of cerebral edema (mannitol, albumin solution, sedatives, drainage of cerebrospinal fluid);
• Symptomatic therapy - for convulsive syndrome (diazepam, thiopental), cerucal for vomiting, fentanyl, haloperidol - for psychomotor agitation;
• Prevention of infectious and inflammatory complications (antibiotic therapy, uroseptics).

Specific drugs for the treatment of hemorrhagic stroke should have a neuroprotective, antioxidant effect, and improve repair in nervous tissue. The most commonly prescribed of them:

1. Piracetam, Actovegin, Cerebrolysin - improve trophism of nervous tissue;
2. Vitamin E, mildronate, emoxypine - have an antioxidant effect.

Consequences and prognosis

Life after a hemorrhagic stroke can create many difficulties not only for the patient himself, but also for his relatives. Long-term rehabilitation, irretrievable loss of many vital functions require patience and perseverance. As a rule, most patients lose their ability to work. In such a situation, it is important to maintain at least the ability for self-care and independent living.

Involves carrying out:

• Physical therapy;
• Massage;
• Physiotherapeutic procedures.

If necessary, a psychotherapist works with the patient; occupational therapy aimed at restoring ability to work and self-care is also useful.

The consequences of a hemorrhagic stroke usually remain for the rest of your life. Disorders of motor and sensory function, speech, and swallowing require constant attention from relatives caring for the patient. If it is impossible to move and walk, it is necessary to ensure the prevention of bedsores (adequate hygiene, especially in cases of dysfunction of the pelvic organs, treatment of the skin). It is also necessary to take into account the possibility of impairment of cognitive functions - attention, thinking, memory, which can significantly complicate contact with the patient at home.

First of all, it consists of a healthy lifestyle, exclusion bad habits, normalization of blood pressure levels. If there are unfavorable hereditary factors, it is important to explain that timely warning will help avoid the development of the disease and its dangerous complications.

Video: hemorrhagic stroke, cerebral hemorrhage

Hemorrhages are blood loss of varying severity that can occur in any part of the human body. The reason for this phenomenon may be various diseases. Most often, hemorrhages are characterized by the accumulation of blood inside the tissues, although blood loss also occurs external character(when blood comes out).

Definition of hemorrhage and the process of its development

Depending on the area in which the damage occurred, hemorrhages are conventionally divided into:

• external (bleeding coming out of a person’s skin);
• internal (blood loss formed in internal organs and tissues);
• venous (moderate bleeding from an opening in the wall of a vessel, resulting from a violation of its integrity);
• arterial (characterized by heavy blood loss caused by damage to the artery);
• capillary (flow of blood from small vessels);
• parenchymal (blood loss from tissues that form organs).

Hemorrhagic syndrome can be either temporary or chronic. Chronic hemorrhages usually occur after the age of 50, as blood vessels become weaker as the body ages.

Causes

There are three types of this pathological phenomenon, which are distinguished according to the reasons for their formation:

• hemorrhage caused by a violation of the integrity of a blood vessel through mechanical damage;
• hemorrhage, the formation of which is caused by a decrease in the thickness of the vessel walls;
• hemorrhage caused by a breakdown in the wall of a vessel, the cause of which was negative impact some chemical substances or infections.

• bruises, fractures, ligament tears;
• surgical interventions;
• high blood pressure;
• aneurysms;
• hypertensive crisis;
• vasculitis;
• leukemia.

Danger of pathology

The danger of hemorrhage is that blood loss can destroy tissue. This may cause more severe consequences, for example, hemorrhage in the brain, lungs and heart.

Symptoms of various types of hemorrhages

For internal bleeding

• apathetic or drowsy state;
• unnatural skin color (appears pale);
• (intense heartbeat - more than 90 beats per minute);
• darkening of the eyes;
• loss of orientation in space, dizziness;
• fainting;
• low blood pressure;
• general malaise;
• dehydration, thirst;
• a sharp decrease in hemoglobin and red blood cells in the blood (determined clinically).

For parenchymal hemorrhage

• feeling of weakness, fatigue;
• dryness in oral cavity, thirst;
• chills, pale skin;
• manifestation of threadlike pulse, decreased blood pressure;
• bad feeling, .

External symptoms of hemorrhage

With hemorrhage in the eye area, redness of the sclera is observed. In addition, in this case, visual acuity decreases.

If a patient has gastric hemorrhage, then the predominant manifestations are the presence of blood in the stool and urine, and nausea.

Diagnosis of pathology

• Blood collection for general analysis. This procedure will help determine the number of leukocytes in the blood, which in turn will make it possible to check damaged tissue for the presence of inflammatory processes.
• MRI. Manipulation will allow you to determine the location of damage to the vessel in any type of hemorrhage.
• X-ray examination. This type diagnostics visualizes possible accumulation of blood in internal organs and tissues.

First aid for hemorrhage

Bleeding from a vein It is easy to determine by the color of the blood coming out: it is dark red. The bleeding intensity will be slow but continuous. The first thing to do in this case is to apply a tourniquet below the wound (10-15 cm) and a tight bandage. It is important to record the time the tourniquet is applied. For small wounds, you can get by with a bandage, since the veins have the ability to collapse on their own.

When arterial bleeding the blood is bright red and flows or gushes out like a fountain. With this type of bleeding, a tourniquet should be applied immediately. If the bleeding is not stopped within a minute, the likelihood of death due to excessive blood loss increases. In case of arterial bleeding, the tourniquet should be applied 10-15 cm above the affected area. A bandage must be applied to the wound. After 1-2 hours, the tourniquet is loosened for 3-5 minutes to allow blood to restore circulation in the extremities, since stagnant blood can accumulate toxic substances. In this case, there is a high probability of developing shock, which causes the death of the victim.

Capillary bleeding are not dangerous (except for injuries in persons with poor blood clotting). In such cases, the affected area is treated and bandaged. To stop this type of bleeding, you can also use hemostatic drugs (Hemostop or Celox). These powdered products promote blood clotting.

Internal bleeding are among the most severe, therefore, if they are detected, you should immediately go to the hospital or call emergency assistance. Before the doctors arrive, the patient should move as little as possible and be in a calm position.

Treatment of hemorrhage

Based on the patient's well-being, clinical form hemorrhages and the level of threat of complications, the doctor determines whether they are appropriate in a particular case medical supplies for the treatment of pathology. For example, for mild subcutaneous bleeding, drug treatment is practically not used. When hemorrhage of the skin occurs with large area lesions, the use of various ointments (troxevasin, heparin) is recommended. They should be applied to the affected areas.

In addition, the following drugs are used for hemorrhages:

• normalizing blood pressure (Enap, Captopril);
• increasing blood clotting (Piracetam);
• anti-inflammatory with analgesic effect (Ortofen);
• local action for resorption of accumulated blood (Indovazin, bodyagi ointment).

Hemorrhagic vasculitis is considered a disease that is a type of immune vasculitis of small vessels and is characterized by increased formation of immune complexes and increased permeability of vascular walls.

This pathology can develop 2-3 weeks after acute tonsillitis, flu or scarlet fever. Hemorrhagic vasculitis is more common in children than in adults.

Children aged 4 to 12 years are especially susceptible to the disease. Boys get sick 2 times more often than girls.

Causes

Why does hemorrhagic vasculitis occur, and what is it? Hemorrhagic vasculitis is also called Henoch-Schönlein disease or capillary toxicosis. The disease is an aseptic (without infection) inflammation of the capillaries caused by the damaging effects of immune complexes. Capillary toxicosis manifests itself as hemorrhages (hemorrhages), impaired intravascular coagulation and impaired blood circulation in small blood vessels.

The principle of the mechanism of development of hemorrhagic vasculitis is the formation of immune complexes. During circulation through the blood, these complexes can be deposited on the internal surfaces of the walls of small vessels and thereby cause damage with subsequent aseptic inflammation.

When the vascular wall becomes inflamed, its elasticity decreases. As a result, it becomes permeable and forms gaps, which leads to fibrin deposits and blood clots. Based on this, pathological sign vasculitis - microthrombosis and hemorrhagic syndrome (bruising).

Classification

Depending on the clinical variant currents hemorrhagic vasculitis occurs:

• skin;
• articular;
• abdominal (that is, from the stomach);
• renal;
• combined. Any combinations are possible. The most common variant is the skin-articular variant, which is otherwise called simple.

Depending on the flow option the disease may be:

• lightning fast (within several days);
• acute (up to 30-40 days);
• protracted (for 2 months or more);
• recurrent ( reappearance signs of the disease 3-4 times or more over several years);
• chronic ( clinical symptoms persist for more than 1.5 years or more) with frequent or rare exacerbations.

Activity level diseases:

• small;
• average;
• high.

Clinical manifestations

Frequency of the main clinical manifestations of hemorrhagic vasculitis in children and adults:

• spotty rashes on the skin (skin hemorrhagic rash) - 100%;
• articular syndrome (pain in ankle joints) - 70%;
• abdominal syndrome (abdominal pain) - 60%;
• kidney damage - 30-35%;

This disease can affect blood vessels in any area, including the kidneys, lungs, eyes, and brain. Hemorrhagic vasculitis without lesions internal organs- the most favorable disease of this entire group.

Symptoms of hemorrhagic vasculitis

In the case of hemorrhagic vasculitis, the symptoms are very varied, but all patients experience skin lesions. It can manifest itself at the very beginning of the disease, or after the appearance of other symptoms. The most typical appearance is purpura - small-spotted (1-3 mm) hemorrhages that are palpable. This rash is symmetrical and is initially located on the feet and legs; later it can spread higher. In addition to purpura, other elements of the rash may also appear (vesicles, petechiae, erythema and even areas of necrosis).

In 70% of patients, symptoms of hemorrhagic vasculitis such as damage to the articular surfaces are detected. This sign often occurs along with rashes in the first week of the disease. Joint damage may be minor and cause short-term painful sensations, but it can also be more extensive, when not only large (ankle and knee) but also small articular surfaces are affected. Swelling occurs and shape changes articular surface, and painful sensations can last from 2 hours to 5 days. However, the disease does not cause severe deformation of the articular surfaces.

The most severe damage is gastrointestinal tract. Sometimes abdominal pain appears even before the rash. They occur when hemorrhages appear on the intestinal wall and are cramping in nature. Often such pain occurs in the navel area, in the right iliac, hypochondrium region and resembles the picture acute abdomen caused by appendicitis, intestinal obstruction or perforation of the ulcer. The pain lasts mostly for three days. But sometimes up to ten days. They are often accompanied by nausea and bloody vomiting, as well as the appearance of blood in the stool. In some cases, intestinal bleeding develops, which is accompanied by sharp decline blood pressure and collapse.

More rare signs of vasculitis include kidney damage in the form of glomerulonephritis and pulmonary syndrome, which is manifested by cough and shortness of breath.

Differences in symptoms between children and adults

In adults:

• The onset of the disease is delayed, the symptoms are milder.
• Abdominal syndrome occurs in only 50% of patients and is rarely accompanied by nausea and vomiting.
• Kidney damage leads to the development of chronic diffuse glomerulonephritis, with the formation of chronic renal failure.

In children:

• More than 30% of children develop fever.
• Characteristic is the acute onset and course of the disease.
• Abdominal syndrome is accompanied by loose stool streaked with blood.
• Often the kidneys are involved in the process from the very beginning, with hematuria and proteinuria detected in urine tests.

Hemorrhagic vasculitis: photo

What does hemorrhagic vasculitis look like on the legs, we offer you to view detailed photos symptoms.

Complications

TO possible complications hemorrhagic vasculitis includes:

• intestinal obstruction;
• perforation of stomach and intestinal ulcers;
• peritonitis;
• posthemorrhagic anemia;
• DIC syndrome with thrombocytopenia;
• thrombosis and heart attacks in organs;
• cerebral disorders, neuritis.

Complications with hemorrhagic vasculitis occur only in cases untimely treatment, so it is very important to start treatment as quickly as possible. It is known that any disease is much easier to treat at the beginning of its development. Self-medication, uncontrolled use medicines or funds traditional medicine will lead to a deterioration in the patient's condition.

Diagnostics

If hemorrhagic vasculitis is suspected, the doctor examines the patient, collects anamnesis, prescribes laboratory and diagnostic examinations that will help you compose full picture illness and prescribe appropriate treatment.

Main diagnostic methods The following examinations are considered hemorrhagic vasculitis:

1. Coagulogram.
2. Detection of circulating immune complexes (CIC).
3. Determination of immunoglobulins of classes A (increased) and G (decreased), cryoglobulins and components of the complement system.
4. Biochemical analysis (protein fractions, CRP, antistreptolysin O, seromucoid).
5. General (detailed) blood test with counting absolute values leukocyte formula indicators.

   Treatment of hemorrhagic vasculitis

   Mild manifestations of skin syndrome may require outpatient (but bed!) rest with mandatory adherence to a special diet (exclusion of meat, fish, eggs, obligate allergens, new products) and prescription drug treatment. However acute period requires hospital stay, constant medical supervision, and in case of involvement of internal organs in the pathological process - the use of large quantity medicines prescribed according to special regimens and in certain dosages.

   The nature of treatment for hemorrhagic vasculitis varies depending on the phase of the disease:

   • debut, relapse, period of remission;
   • clinical form - simple (skin), mixed, with kidney damage;
   • severity of clinical manifestations - mild (satisfactory health, mild rashes, possible joint pain), moderate (multiple rashes, joint pain or arthritis, periodic pain in the abdomen, traces of blood or protein in the urine), severe (drainage rashes, elements of necrosis, recurrent angioedema, persistent abdominal pain, gastrointestinal bleeding, blood in urine, nephrotic syndrome, acute renal failure);
   • nature of the course of the disease - acute (up to 2 months), prolonged (up to 6 months), chronic (recurrent or development of Schönlein-Henoch nephritis).

   The drug treatment regimen includes:

   1. Disaggregants - chimes 2-4 milligrams/kilogram per day, trental intravenous drip.
   2. Heparin at a dosage of 200-700 units per kilogram of body weight per day subcutaneously or intravenously 4 times a day, gradually withdrawn with a decrease in the single dose.
   3. Activators of fibrinolysis - nicotinic acid.
   4. At severe course plasmapheresis or glucocorticosteroid therapy is prescribed.
   5. In exceptional cases, cytostatics such as Azathioprine or Cyclophosphamide are used.

   The duration of treatment for hemorrhagic vasculitis in children and adults depends on the severity of the disease and its clinical form. Usually it takes 2-3 months mild flow, 4-6 months for moderate and up to a year for severe Henoch-Schönlein disease, accompanied by relapses and nephritis.

   Treatment of patients with hemorrhagic vasculitis is complicated by the fact that there are currently no drugs that effectively suppress the underlying pathological process, regardless of its location. It is necessary to exclude exposure to known active antigenic influences, especially those that chronologically coincided with the clinical manifestations of the disease.

   

   Diet

   It is very important during treatment to prevent additional sensitization of the patient. Therefore, it is necessary to follow a diet that excludes extractives, chocolate, coffee, citrus fruits, strawberries, eggs, industrial canned food, as well as foods that are poorly tolerated by the patient.

   Special diets are additionally prescribed for severe abdominal or renal syndromes. Thus, for severe nephritis, it is recommended to follow diet No. 7 without salt and meat.

   Which doctor should I contact?

   Hemorrhagic vasculitis in children and adults is treated by a rheumatologist. In case of defeat various organs consultation with specialized specialists is necessary: ​​dermatologist (skin), gastroenetrologist (intestines), neurologist (brain), nephrologist (kidneys), cardiologist (heart), pulmonologist (lungs). It is advisable to see an immunologist for timely diagnosis complications after taking medications.

   Forecast

   With hemorrhagic vasculitis, the prognosis is quite favorable. In rare cases, death may occur in the acute phase of the disease due to complications from the gastrointestinal tract (bleeding, intussusception, intestinal infarction). Fatal outcome may also be a consequence of acute renal failure or damage to the central nervous system.

   Some patients with hemorrhagic vasculitis may develop chronic kidney disease. In approximately 25% of patients with kidney damage in the acute phase of the disease, changes in urine sediment persist for a number of years; the final outcome of the disease in such patients is unknown.

With the normal functioning of hemostatic mechanisms, hemorrhages do not develop spontaneously, and injuries to most vessels (with the exception of injuries large arteries, main veins and the vascular network of parenchymal organs) do not threaten the patient’s life due to the local formation of a fibrin clot at the site of damage to the vascular bed. Numerous coagulation defects prevent the physiological implementation of hemostatic reactions, therefore, in case of gross violations of the hemostatic system, even minor vascular damage can cause the patient’s death. It should also be taken into account that in a considerable number of patients, hemorrhagic syndrome is caused not by vascular injury, but by other reasons ( inflammatory process, separation of the placenta, destruction of the mucous membrane or hormonally induced endothelial rejection during menstruation, etc.).

Nature provided to the human body quite a wide range of concentrations for each of the coagulation factors. In addition, the level of isolated reduction in any coagulation factor that causes hemorrhage is approximately 5-10 times lower than the average normal value.

It is very important to detect a hemostatic defect as early as possible, since patients with even moderate bleeding during and/or after surgery or childbirth can lose a fairly large volume of blood. In such situations, the attending physician will no longer have the opportunity for a more precise diagnosis, since life-threatening hemorrhages often induce consumption coagulopathy, which will result in depression of most components of the hemostatic system (platelets, fibrinogen and many others), which will not allow identifying the underlying hemostatic defect uncontrollable bleeding.

In 1975 prof. Z.S. Barkagan developed a simple but very useful classification of hemorrhage variants. The author of this classification identified five main types of bleeding: hematomal, microcirculatory, mixed, vasculitic purpuric and angiomatous. In table 2.3 presents the characteristics of these five types of bleeding, and also shows in which hemorrhagic diseases one or another variant develops. Despite its simplicity, this classification reflects not only the clinical and morphological features of hemorrhages, but also the pathogenetic mechanisms that determine them, therefore it has been an effective diagnostic tool for about 40 years.

Causes of hemorrhagic syndrome

HS due to blood clotting disorders (coagulopathy):

• Hemophilia.
• Lack of prothrombin.
• Overdose of anticoagulants.

HS due to impaired platelet formation:

• Werlhof's disease.
• Symptomatic thrombocytopenia.
• Thrombocytopathies.

3. HS due to vascular damage (vasopathy):

• Hemorrhagic vasculitis.
• Hemorrhagic telangiectasia.

There are 5 types of bleeding

1. Hematoma type. It is characterized by massive painful hemorrhages in the muscles, as well as in large joints. This type is characteristic of hemophilia.
2. Petechial-spotted type (bruise). It is characterized by painful superficial bleeding into the skin and bruising. Hemorrhages occur with negligible trauma (for example, when measuring blood pressure). This type is characteristic of thrombocytopathy, and may be due to a lack of fibrin and certain coagulation factors (X, V, II).
3. Mixed bruise-hematoma type. It is characterized by a combination of petechial-spotted bleeding with large hematomas in the absence of hemorrhages in the joints (in contrast to the hematoma type). This type is observed with factor XIII deficiency, overdose of anticoagulants, and constitutional thrombocytopathies.
4. Vasculitic purpuric type. It is characterized by skin hemorrhages in the form of purpura. This type is characteristic of hemorrhagic vasculitis and thrombocytopathy.
5. Angiomatous type. It is characterized by repeated bleeding of a certain localization. This type is observed with telangiectasias and angiomas.

Petechia is a small spot (1-3 mm) of a certain shape of purple-red color. Does not disappear when pressed.
Purpura is a subcutaneous layer of tissue, altered due to hemorrhage, purple or red-brown in color, easily visible through the epidermis.
Echimosis is a hemorrhagic spot (larger than petechiae) of blue or purple color.

Symptoms and signs of hemorrhagic syndrome

The clinical picture consists of bleeding symptoms various localizations and skin hemorrhagic rashes.

Bleeding may occur spontaneously or under the influence external factors: hypothermia, physical stress, minor injuries. Skin manifestations hemorrhagic diathesis is diverse - from small petechial rashes and bruises to hemorrhages merging with each other with an ulcerative-necrotic surface. The variety of clinical manifestations of the syndrome corresponds to five types of bleeding.

Hemorrhagic manifestations can be combined with articular syndrome (arthralgia, hemarthrosis), abdominal syndrome, and there may be an increase in temperature.

Hemorrhagic syndrome can be observed in diseases such as malignant neoplasms, hepatitis and cirrhosis of the liver, leukemia, sepsis, systemic diseases connective tissue, severe infections etc. In such cases, the clinical picture will consist of the symptoms of the underlying disease and the symptoms of hemorrhagic diathesis.

Laboratory and instrumental studies

1. Expanded clinical analysis blood with platelet count.
2. Blood clotting time.
3. Duration of bleeding.
4. Blood clot retraction time.
5. Blood for prothrombin and fibrinogen.
6. Plasma tolerance to heparin.
7. General urine analysis.
8. Sternal puncture according to indications.

If necessary, the scope of laboratory tests can be expanded (thrombin and prothrombin time, determination of the activity of coagulation factors, determination of antihemophilic globulin, study of the adhesive-aggregation function of platelets, recalcification time).

Stages of diagnostic search

1. The basis of the diagnostic algorithm is the presence of hemorrhagic syndrome. For this purpose, when collecting complaints, it is necessary to clarify the location and nature of bleeding, the frequency of bleeding, find out whether the bleeding is associated with any provoking factor or occurs spontaneously, etc.
2. The second stage is the history and physical examination. If the disease manifests itself from early childhood, it is natural to assume that the disease is hereditary or congenital (in this case, it is important to collect information about the presence of similar symptoms in close relatives).

Since most acquired hemorrhagic diathesis are symptomatic, it is necessary to clarify the presence of the underlying pathology. These may be liver diseases, leukemia, radiation sickness, aplastic anemia, systemic connective tissue diseases. Bleeding may be associated with the action of drugs that affect platelet function (aspirin) or blood clotting (anticoagulants).

An objective examination involves a thorough examination of the skin, which will determine the nature and type of hemorrhagic manifestations. Inspection of the mucous membranes is mandatory, since hemorrhages can be located not only in the skin, but also in the mucous membranes. In some cases, angiectasias can be detected in the form of vascular spiders or bright red nodules protruding above the surface of the skin. They are characteristic of hereditary vascular dysplasias ( Rendu disease- Osler) or can be acquired (for example, with cirrhosis of the liver).

Enlargement of joints with limited mobility occurs in hemophilia. These disorders are a consequence of bleeding in the joints (hemarthrosis).

With hemorrhagic vasculitis there may be a slight increase lymph nodes. Autoimmune thrombocytopenia accompanied by an enlarged spleen.

Tests for capillary resistance (fragility) may have diagnostic value:

1. Rumple-Leede-Konchalovsky symptom.
2. Pinch symptom - if you pinch the skin under the collarbone, you will see pinpoint hemorrhages. When a suction cup is applied to the skin, pinpoint hemorrhages appear. These tests are positive in cases of thrombocytopenia, hemorrhagic vasculitis, and taking anticoagulants.
3. Additional research methods will help establish a final diagnosis.

Differential diagnosis of hemorrhagic syndrome

Bleeding can be detected in diseases whose pathogenesis does not involve a defect in the hemostatic system, so the greatest difficulty in examining such patients is to determine the etiology of the hemorrhagic syndrome. With defects in the hemostatic system, hemorrhages of different localization and other clinical manifestations of hemostatic dysfunction are usually combined with each other (for example, epistaxis and uterine bleeding), forming an idea of ​​​​the systemic nature of manifestations, which is very characteristic of most hemorrhagic diseases. In addition, with hemorrhagic diseases and syndromes, recurrent hemorrhages are often combined with chronic posthemorrhagic anemia. However, in a number clinical cases There are also local hemorrhagic manifestations without other symptoms of bleeding and iron deficiency. In the presence of local hemorrhages or asymptomatic bleeding, it is only possible to exclude a hemorrhagic disease laboratory test hemostasis systems. If one or two clinical manifestations of bleeding are detected, it is useful to consider their relationship with a hemorrhagic disease.

When carrying out differential diagnosis of various types of hemorrhagic diathesis, one should be guided by the following considerations.

1. Identification of coagulopathies from the group of hemorrhagic diathesis is based on clinical features bleeding (hematoma type, often hemarthrosis, delayed bleeding), laboratory coagulation studies (extension of clotting time, thrombin, prothrombin and thromboplastin time), as well as negative results tests for capillary fragility.
2. Hemorrhagic diathesis due to impaired platelet formation is characterized by a petechial-spotted type of bleeding and bleeding from the mucous membranes, positive samples on capillary fragility (symptom of a tourniquet, pinch), a decrease in the number of platelets or their functional failure.
3. Vasopathies are diagnosed by vasculitic purpuric or angiomatous type of bleeding and unchanged laboratory data.
4. The diagnosis of hereditary forms is based on the study of family history and laboratory data.
5. The diagnosis of symptomatic forms is based on identifying clinical signs one or another (main) disease, taking into account the characteristics of the manifestation of hemorrhagic syndrome. Other purchased hemorrhagic diathesis can be diagnosed only after excluding symptomatic variants.

Paramedic tactics for hemorrhagic syndrome

1. In case of bleeding, provide emergency assistance to the extent necessary and possible.
2. If a patient with hemorrhagic syndrome is identified, give a referral for consultation with a doctor.
3. After establishing a diagnosis, the paramedic monitors patients who are subject to medical examination, working in contact with the doctor.
4. The paramedic must know all the patients in his area who suffer from hemophilia, and have an idea of ​​modern methods of treating it (coagulation factor VIII concentrate - in mild cases 10-15 units/kg, in more severe cases 25-40 units/kg per course of treatment; for hemorrhages in the cavity of the skull, chest, abdomen, the initial dose is 40-50 units/kg).

Hemorrhagic diseases and syndromes are pathological conditions characterized by increased bleeding as a result of insufficiency of one or more elements of hemostasis.

Etiology

There are hereditary and acquired forms of hemorrhagic diseases and syndromes.

Hereditary forms are associated with genetically determined pathological changes in the vascular wall, anomalies of megakaryocytes, platelets, adhesion proteins of blood plasma and plasma factors of the blood coagulation system.

Acquired forms in most cases are caused by damage blood vessels immune, immunocomplex, toxic-infectious and dismetabolic etiology (various vasculitis), damage to megakaryocytes and platelets of various etiologies (thrombocytopathy), pathology of adhesion proteins of blood plasma and factors of the blood coagulation system and multifactorial disorders of the blood coagulation system ( acute syndromes ICE).

Kinds hemorrhagic diseases

Based on their origin, the following types of hemorrhagic diseases and syndromes are distinguished: vasculitis, thrombocytopenia, thrombocytopathy, coagulopathy, DIC.

Vasculitis. Caused by primary damage to the vascular wall with the possible secondary development of coagulation and platelet disorders. This group includes hereditary hemorrhagic telangiectasia Randu–Osler, syndrome Ehlers –Dunlo , syndrome Marfana , giant hemangiomas in the syndrome Kazabakh–Merritt, hemorrhagic vasculitis Schönlein–Henoch, erythema, hemorrhagic fevers, hypovitaminosis C and B, etc.

Thrombocytopenia. They develop as a result of primary damage to the megakaryocyte-platelet lineage, redistribution of platelets and their deposition in the spleen, increased destruction (for example, in SLE or idiopathic thrombocytopenic purpura), increased consumption of platelets and the formation of blood clots (DIC, thrombotic thrombocytopenic purpura), and the use of certain drugs.

Thrombocytopathies. Characterized by the presence of abnormal platelets with disruption of their functions. The most common among them is thrombasthenia Glyantsmann and illness background von Willebrand .

Coagulopathies. Caused by blood clotting disorders.

† Hereditary coagulopathies: hemophilia A, hemophilia B, disease background von Willebrand , deficiency of blood clotting factors;

† Acquired coagulopathies: vitamin K-dependent coagulopathies (occur with insufficient liver function, impaired absorption of vitamin K, nutritional deficiency of vitamin K, taking drugs such as coumarin), disseminated intravascular coagulation, liver pathology (leads to a deficiency of many coagulation factors), pathological coagulation inhibitors ( lupus anticoagulant; specific coagulation inhibitors - ATs specific to individual coagulation proteins);

† Impaired fibrin stabilization, increased fibrinolysis, including during treatment with direct and indirect anticoagulants, fibrinolytics (streptokinase, urokinase, alteplase, etc.);

† Other acquired coagulation disorders: Deficiency of clotting factors can occur with somatic diseases (for example, with amyloidosis - factor X deficiency).

ICE. They are a consequence of complex disorders of various parts of the hemostasis system.

Types bleeding

The following types of bleeding are distinguished.

Capillary or microcirculatory (petechial-bruise) type of bleeding. Characterized by petechial rashes, bruises and ecchymoses on skin and mucous membranes. Often combined with increased bleeding of the mucous membranes (nosebleeds, menorrhagia). Severe hemorrhages in the brain may develop. This type of bleeding is characteristic of thrombocytopenia and thrombocytopathies, diseases background von Willebrand , insufficiency of prothrombin complex factors (VII, X, V and II), some variants of hypo- and dysfibrinogenemia, moderate overdose of anticoagulants.

Hematoma type of bleeding. It is characterized by painful, intense hemorrhages in the subcutaneous tissue, muscles, large joints, peritoneum and retroperitoneal space. Hematomas can lead to compression of nerves, destruction of cartilage and bone tissue, dysfunction of the musculoskeletal system. Sometimes renal and gastrointestinal bleeding develop. Prolonged bleeding is typical from cuts, wounds, after tooth extraction and surgical interventions, often leading to the development of anemia. This type of bleeding is observed in some hereditary bleeding disorders (hemophilia A and B, severe deficiency of factor VII), acquired coagulopathies, accompanied by the appearance of inhibitors of factors VIII, IX, VIII + V in the blood, and with an overdose of anticoagulants, as well as in hereditary thrombocytopathy with absence of lamellar factor 3.

Mixed capillary-hematoma type of bleeding. It is characterized by petechial bruises, combined with extensive dense hemorrhages and hematomas. Observed in hereditary (severe deficiency of factors VII and XIII, severe form of the disease background von Willebrand ) and acquired (acute DIC syndromes, significant overdose of direct and indirect anticoagulants) disorders.

Vasculitic purpuric type of bleeding. It manifests itself as hemorrhagic or erythematous (inflammatory-based) rashes, the development of nephritis and intestinal bleeding is possible; observed in infectious and immune vasculitis.

Angiomatous type of bleeding. It is characterized by repeated strictly localized bleeding associated with local vascular pathology. Observed for telangiectasis, angiomas, arteriovenous shunts.

Basic causes bleeding

The main causes of hypocoagulation and bleeding are presented in Fig. 21–27.

Rice. 21–27. The main causes of hypocoagulation of blood proteins and hemorrhagic syndrome.

Mechanisms Hypocoagulation

The mechanisms of hypocoagulation and bleeding are presented in Fig. 21–28.

Rice. 21–28. Basic mechanisms of blood hypocoagulation and hemorrhagic syndrome.

Hemorrhagic diseases and syndromes can be caused by pathologies of blood vessels (vasopathies), platelets (thrombocytopathies), and the hemostatic system (coagulopathies).

Hemorrhagic diseases, conditional pathology vessels

Typical diseases of this group are Randu–Osler, purple Schönlein–Henoch, primary hemorrhagic vasculitis.

Disease Randu–Osler

Randu–Osler–Weber disease (hereditary hemorrhagic telangiectasia, hereditary hemorrhagic angioma, disease Osler–Weber, disease Osler) - hereditary () angiopathy, manifested by multiple telangiectasia and hemorrhagic syndrome. Frequency. 1:16,000 population.

Treatment and prevention

To stop bleeding, local and general hemostatic therapy is used (irrigation with thrombin solution and 5% aminocaproic acid solution, nasal tamponade with oil swabs, detachment of the mucous membrane in the area of ​​bleeding, cauterization). Cryotherapy is more effective. Sometimes it is necessary to resort to surgical treatment (excision of angiomas, plastic surgery of the nasal septum, ligation and embolization of arteries). Barotherapy and laser cauterization are also used. With concomitant factor deficiency background von Willebrand Transfusions of fresh frozen plasma and administration of cryoprecipitate are carried out. If anemia develops, blood transfusions are performed and iron supplements are prescribed.

Patients should avoid traumatizing the mucous membranes at the sites of angiomas. The nasal mucosa is lubricated with lanolin (with thrombin) or neutral oils. When getting married, medical genetic counseling is necessary.

Hemorrhagic vasculitis

Hemorrhagic vasculitis (anaphylactoid purpura, immune complex vasculitis, disease Schönlein–Henoch) - bleeding caused by damage to small vessels by immune complexes and components of the complement system (see the article “Purpura” in the Appendix “Reference of Terms” on the CD).

Hemorrhagic syndromes, conditional pathology platelets

Hemorrhagic syndromes caused by platelet pathology (thrombocytopenia and thrombocytopathy) include idiopathic thrombocytopenic purpura, thrombasthenia Glyantsmann , syndrome Bernard –Soulier(See the Pathophysiology of Platelets section in Chapter 21 and related articles in the Reference Guide appendix on the CD.)

Hemorrhagic diseases, conditional violations coagulation systems blood

The stages of the hemocoagulation cascade are presented in Fig. 21-25.

Kinds coagulopathies

Hereditary coagulopathies.

Deficiency of factor VIII components (hemophilia A, disease background von Willebrand ) and factor IX (hemophilia B); these are the most common hereditary coagulopathies (more than 95% of cases). See the article “Hemophilia” in the Terms Reference appendix on the CD-ROM.

Deficiency of factors VII, X, V and XI (0.3–1.5% of cases each).

Deficiency of other factors: XII (defect Hageman), II (hypoprothrombinemia), I (hypodysfibrinogenemia), XIII (fibrin-stabilizing factor deficiency) are extremely rare (single observations).

Acquired coagulopathies.

DIC syndrome.

Deficiency or inhibition of the activity of prothrombin complex factors (II, VII, X, V) in liver diseases, obstructive jaundice, intestinal dysbiosis, overdose of vitamin K antagonists (coumarins, phenylin), hemorrhagic disease of newborns.

Coagulopathies associated with the appearance in the blood of immune inhibitors of coagulation factors (most often antibodies to factor VIII).

Bleeding caused by heparinization, administration of fibrinolytic drugs [(streptokinase, urokinase, alteplase (actilyse)] and defibrinating action.