Thursday, September 23, 2010

3.4a Bleeding & Transfusion

Physician's Notebooks 3 - - See Homepage

3.4a Bleeding & Transfusion - Update 27 November 2018
The major risk factors for hemorrhage other than trauma are the use of medications like coumadin aka Warfarin or the heparin anticoagulants, the use of anti platelet aggregation medications like aspirin and related NSAIDs, and conditions like diverticulosis with high blood pressure that tends to blow out small arterioles in the intestine and brain.
   Diverticulosis: I have it. Most persons do not realize its potential for life-threatening hemorrhage. As its name suggests, diverticulosis is the presence of many diverticula (singular diverticulum), which are like an anatomic appendix. But unlike the appendix, which occurs singly in  the cecum start of large intestine, they occur in the mid or distal large intestine in high numbers (I have 20). Some diverticuli get clogged and infected (diverticulitis) and become surgical. And the other complication is hemorrhage often in persons with other risk factors for bleeding. Its rate in diverticulosis is <1% but it is a big problem because hard to locate the exact place of bleeding and it involves arteries that bleed out rapidly. If you have diverticulosis, avoid full-dose aspirin or NSAIDs and take acetaminophen instead for pains or fever; and keep your coumadin medication, if you must take it, under very careful INR control; and get your hypertension treated to normalize your BP.
   Since so many of the population today in soon-to-be 2019 take either aspirin or coumadin or other anticoagulant to prevent blood clots, it is important for all to know the signs of less obvious abnormal bleeding. The GI bleeding - from the esophagus, stomach and duodenum (upper GI) - as long as it is moderate, presents as coffee-ground vomit or charcoal-black stool. The black may also be caused by taking iron or bismuth medicines (Pepto Bismol) but get a test done to be sure it is not blood. In cases with small amonts of bleeding, so-called occult-bleeding, that cannot be seen by gross vision, the heme-occult test may be ordered. When you test for occult bleeding, three separate stool samples from three consecutive days should be sampled. It is a very useful test because simple, inexpensive and noninvasive so it can be repeated almost forever. With very heavy upper GI bleeding or from the colon and rectum, the blood is obvious. Similarly, vaginal bleeding in a woman.

Blood Transfusions can be life saving but should require your careful thought and decision. The worst problem today is transmission of HIV/AIDS and Mad Cow Disease and even though pre transfusion testing in the USA and other advanced countries has markedly reduced the risk; still, it is a super tragedy that will doom a life to unhappiness and premature death. With HIV, two factors work in favor of transmission: 1) A "window of opportunity" of 1 month during which a newly acquired HIV infection may test negative for HIV by the pre test screening, and 2) a recent relaxing of the requirement that homosexual men cannot donate blood. (Also in some areas, the blood supply for transfusions is being supplemented by purchased donations from Africa and SE Asia) Add to this that bisexual men and drug-shooting, recently-acquired HIV infections may slip past the pre test screening and we have a cause for worry. Blood transfusions also have lesser but still serious risks that you may check on Internet.
   So, what "careful thought"?
   If a blood transfusion is suggested, be sure you really need it. If there is time, get a 2nd opinion. If you need the transfusion, try to get it from persons you know and trust not to be risks for HIV (close family, friends, professional colleagues). If you will be having elective surgery, do it at a place where you may donate your own blood ahead of time to be used on yourself if needed at surgery. Finally, check for anemia (low red blood cells) and get it treated before it needs blood transfusion.
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