GU/GI Bleeding
Initial presentation Acute abdominal pain in a patient with hemophilia may have many origins, such as GI tract hematomas (both spontaneous or trauma induced), pseudotumors, iliopsoas or retroperitoneal bleeding. Bleeding may also occur with hemorrhoids or the passage of kidney stones. Notify the hemophilia treatment center or the patient's hematologist. Patients who present to the emergency department with abdominal or flank pain, melena or hematemesis should be triaged for immediate examination and given factor replacement therapy at the major dosage. After factor therapy, then diagnostic x-rays, scans and endoscopy procedures can be carried out. Abdominal trauma and benign events such as forceful coughing or vomiting can precipitate an abdominal bleed. Blood loss can be significant before outward signs and symptoms appear. Infants can have bleeds with gastroenteritis, intussusception or Meckel's Diverticulum. A history of lifting heavy objects, weight lifting, falling on bicycle handlebars or stretching the groin can precipitate abdominal wall, iliopsoas (see pages 8 and 9), or retroperitoneal bleeding. Symptoms Symptoms of abdominal muscle bleeding (rectus, pectorals, latissimus, obliques) are a palpable mass, rigidity, and pain. Concurrent bleeding in the abdominal cavity may be present and go unnoticed for days with a steadily dropping hemoglobin. Rupture of the liver, spleen, or pancreas should be considered when the hemoglobin falls dramatically following trauma. For nausea and vomiting without an obvious cause, consider that these may be symptoms of intracranial bleeding. Inquire about head injury, mental status changes, and other neurologic signs and symptoms, and consider CT scan of the head. Genitourinary bleeding Hematuria is often frightening to the patient but not a serious event. Instruct the patient to remain at bed rest and force fluids the next 24 hours. Protracted hematuria may require a routine dose of factor coverage. Anti-fibrinolytics are contraindicated with hematuria. Contact the hematologist. Scrotal bleeding may occur after trauma, especially in toddlers. Infuse with a routine factor dose and have the family contact the patient's hematologist for follow-up care. Discharge Instructions - force fluid for hematuria - rest - no weight lifting - report any symptoms - follow-up with the hemophilia treatment center or the patient's hematologist.