Bleeding disorders

The primary objective of this chapter is to deal with the most important bleeding disorders from a dental point of view. An understanding of the disorders discussed in this section hinges upon a basic knowledge of the various physiological processes involved in normal haemostasis (AU)

Haemorrheological disturbance in diabetes mellitus - abstract

Diabetes mellitus is one of several metabolic diseases in which haemorrheological disturbances have been observed. In diabetes, particularly of long duration, there are marked alterations of the microcirculation. These changes are associated, at least in part, with rheological disturbances. Diabetic microangiopathy affects the retina, the enal glomeruli, the nerves and probably the entire network of capillaries. Rheological studies in both insulin-dependent (IDDM) and non-insulin-dependent (NIDDM) diabetics have shown a decrease in red cell deformability, an increase in red cell aggregation and plasma fibrinogen concentration. These alterations are aggravated by concurrent hypertension and the severity of the disease. The combined effect of these changes is the development of a hyperviscosity syndrome in the diabetic patient. The clinical significance of diabetic hyperviscosity is a marked impairment in blood-flow, in particular, across the microcirculation; hence diminished tissue perfusion (AU)

Childhood vaginal bleeding in Trinidad

In a review of 40 girls with vaginal bleeding in Trinidad the predominant causes were accidental falls (45 percent) and prolapsed urethral mucosa (36.5 percent). All 3 cases of sexual abuse sustained solely vaginal (internal) lacerations compared to the other 18 with falls where only vulval (external) lacerations were discovered. Foreign bodies and worms found in the vagina, vulvo-vaginitis and a cavernous haemangioma were less common aetiological factors

Mortality of Jamaican patients with systematic lupus erythematosus

A retrospective study of all patients with systemic lupus erythematosus (SLE) who died at the University Hospital of the West Indies over a 14-year period is presented. The major cause of death was infection followed by renal failure. Gram-negative organisms were the major microbiological agents causing infections. Side-effects of therapy were common, in particular bone marrow depression and haemorrhage related to anticoagulants. It appears that controlling severe lupus activity without increasing the risk of life-threatening complications remains an important goal in the treatment of SLE.(AU)

Clinical indicators of advanced endometrial pathology in postmenopausal bleeding - abstract

One hundred and nine patients with postmenopausal bleeding who underwent a fractional dilation and curettage were studied over a 52-year period. Malignancies were found in 20.2 percent of the study group; 11.9 percent were endometrial carcinoma and 7.3 percent squamous carcinoma of the cervix. Forty-five per cent of the patients were discovered to have some form of organic pathology. Compared with the 30 patients who had an atrophic endometrium, those with endometrial carcinoma had an increased mean age of menopause (64 vs 49 yrs), a lower parity (4.2 vs 7.5), a lower haemoglobin level (11.5 vs 13.2g/dl) and a larger uterine size (85 percent vs 10 percent>6wk size). Bleeding was for more than 1 month in 85 percent compared with 15 percent in the atrophic group and it was more frequently heavy, resembling menses (77 percent vs 37 percent). This study points to a low haemoglobin level, heavy menses like bleeding and bleeding for more than one month as clinical features indicative of the presence of advanced endometrial pathology (AU)

Incidence, aetiology and outcome of pregnancies complication by antepartum haemorrhage in Trinidad - abstract

A 4-year retrospective review of 124 consecutive cases of antepartum haemorrhage from 21,974 deliveries was performed in order to determine the incidence, aetiology and outcome of those pregnancies complicated by antepartum in our population. An incidence of 0.56 per cent was found. Placenta previa and placental abruption were present in 1 of every 600 and 1 in 470 pregnancies repsectively, while the incidence of an indeterminate cause of bleeding was 1 in 550 deliveries. Induced first trimester abortion was found to be a significant factor predisposing to placenta praevia. The higher incidence of the latter with advancing age and parity and the association of hypertensive disorders in pregnancy with an increased risk of abruption were confirmed in this study. In cases of abruptio placentae, when vaginal delivery was no imminent, caesarean section reduced foetal loss (AU)

Maternal mortality in Jamaica: a confidential enquiry into all maternal deaths in Jamaica 1981 to 1983

This paper presents an analysis and confidential enquiry into all maternal deaths occurring in Jamaica during the years 1981 to 1983. Details were obtained of all maternal deaths, irrespective of whether they occurred in hospitals or at home, during this three year period. Anonymous case summaries were prepared for all maternal deaths. These case summaries contained general characterisitics of the women, e.g. age and parity, details of the health care (if any) they had received and specific circumstances surrounding their deaths. Each case summary was independently assessed by two practicising Jamaican obstetricians from a panel of seven. They were specifically asked to comment as to whether there were any avoidable factors present in each death which, in their opinion and given their knowledge of current generally accepted standards of satisfactory medical care in Jamaica, may have increased the likelihood of death. Such departures from accepted standards include failure of patients to utilize or cooperate with services, as well as failure to provide or offer adequate care (AU)

Oesophageal varices - abstract

The treatment of bleeding oesophageal varices remains a frustrating exercise for physicians and surgeons. At the University Hospital of the West Indies, during the period January 1971 to December 1982, 53 patients were admitted with bleeding oesophageal varices. The diagnosis was confirmed by barium meal, oesophagoscopy, surgery or at post-mortem. Thirty-nine of these were males. Their ages ranged from 11 to 81 years. Forty-two belonged to the 40 to 60-year age group. Initially, all patients were treated with blood transfusion, intravenous pitressin and the Sengstaken Blakemore tube. In 10 patients the bleeding stopped and they were discharged home. Of the remaining 43 patients, 29 died without surgery. Sixteen patients died within 3 days of admission, 7 patients were not fit for surgery and 6 refused operation. Fourteen patients underwent surgery. Eleven had an emergency surgical procedure to control bleeding and only 3 of these survived. Three patients had elective operations following conservative control of bleeding and all of them survived. The overall mortality form bleeding oesophageal varices of 70 percent reflects our difficulty in controlling bleeding adequately in the initial stages as a prelude to elective portal decompression in these patients. The reason for this are: (a) difficulty in monitoring the patients with Sengstaken-Blakemore tube on the general wards, and the frequent non-availability of the tube, (b) difficulty in obtaining adequate amounts of blood, and (c) lack of early surgical intervention in cases where bleeding is not controlled by conservative means. It is our belief that patients with acute variceal haemorrhage should be manged in an Intensive Care Unit. In this setting we are more likely to be able to control bleeding and to prepare the patient for elective surgery. We also need to develop a more aggresive approach to those patients whose bleeding is not promptly controlled and to advise surgical intervention before the general conditions of the patient deteriorates to a point where he is no longer fit for surgery (AU)

Epidemic acute hemorrhagic conjunctivitis in Belize

Acute hemorrhagic conjunctivitis was first introduced into Belize in July 1981, during the course of a larger Caribbean epidemic. The index case apparently arrived by boat from Honduras. The disease spread rapidly from the coastal centers of Belize City and Dangriga, the first urban areas affected, and within two weeks all the districts in the country were reporting cases. Peak attack rates generally occurred about four weeks after the initial cases. Countrywide, government clinics reported 121 cases of acute hemorrhagic conjunctivities for every 1,000 inhabitants. Data from different census enumeration districts in Belize City indicated attack rates ranging from 0 to 417 cases per 1,000 inhabitants. Statistically significant correlations were observed between the Belize City data and other data on adult education and census district population size. The limited data available also suggest that the disease showed slight dependence upon conditions prevailing in the tropical coast-city environment that constitutes its typical setting. Instead, very similar epidemic patterns appear to have emerged in coast cities and inland farming areas; and the main factor limiting the outbreak appears to have been restrictions on the opportunities for the disease to suggests that the disease's decade-long absence from the Americas did not result from intrinsically unsuitable conditions, but rather from its lack of an effective introduction to the Region.(AU)

Hypertension and the brain

Major brain illnesses attributable to arterial hypertension include: (a) Infarction - Cerebral/Lacunar (b) Encephalopathy (c) Haemorrhage. Arterial hypertension affects the capacity of the crebral arteries to volumetrically regulate CBF and causes structural changes in the arterial wall. The deficits resulting from lacunar infarction can be substanial if important structures are involved. Primary hypertensive brain haemorrhage has been called an "Oh, my head" syndrome, because these words are often among the last conscious utterances of the affected patient. The putamen, internal capsule and thalamus are the most common sites of origin for hypertensive intracerebral haemorrhage and are best distinguished clinically by examination of eye movement. In patients with primary hypertensive intracerebellar haemorrhage, rapid surgical intervention can yield gratifying results. The decline in the incidence of strokes correlates positively with improving detection and more efficient treatment of vascular hypertension. The only adequate treatment of stroke is prevention (AU)

An elective project on maternal mortality at U.H.W.I. - 1976-1980

Maternal deaths in th 1975-80 period, UHWI were analysed as an elective project. Most deaths were referred from other hospitals. Most deaths were preventable and the traditional triad of haemorrhage, infection and toxaemia were responsible for most deaths (AU)

Crippling giant keloid

Keloids occur commonly in dark-skinned races on the face, the neck and the front thorax. One such patient, a Negro man aged 50, in whom an unusually large tumour-like keloid caused disability, disfigurement and social seclusion, was seen at University Hospital of the West Indies. He was wheeled into the surgical clinic supporting in his lap a large mass wrapped in dressing, hanging from his chin. He was unable to move his head sideways because of the heavy object dragging on his neck (AU)

Pregnancy in a Jamaican with Von Recklinghausen's disease

A rare case of pregnancy in a patient with von Recklinghausen's disease and disability due to childhood poliomyellitis is presented. The interesting but serious complication was the sudden onset of haemorrhage in the tumours which treated satisfactorily with conservation management. Posible complications are discussed and the literature on the subject is reviewed (AU)

A review of the aetiology and pathogenesis of acute pancreatitis: part 1: Classification, role of infection, common channel theory and duodenal reflux

There are still contradictory opinions concerning the aetiology and pathogenesis of acute pancreatitis. The problem of lymphatic spread of infection from the biliary tract to the pancreas, which in the thirties was considered as improbable, has been re-opened by the results of more recent investigations. The common channel theory which was once considered to be the explanation for most cases of pancreatitis, can account for only a small proportion of cases of pancreatitis. There is still lack of agreement as to the role of duodenal reflux in the causation of pancreatitis (AU)

Hepatic artery ligation in liver trauma

Hepatic artery ligation can be successfully employed to control massive bleeding from hepatic trauma. Debridement and resection will be required for devitalized segments of hepatic tissue. Survival depends on adequate collateralarterial circulation, as well as increased oxygen supply from the portal venous blood. Avoidance of factors such as shock and sepsis will decrease morbidity and mortality. The successful management of a case of liver trauma by hepatic artery ligation is presented (AU)

Massive pancreatic ascites

A case of massive bloody ascites is described. This was associated with a benign pseudocyst of the pancreas of undetermined etiology. The ascites recurred after drainage but has not recurred after drainage of the pseudocyst (AU)