Differential diagnosis of hemorrhages

How to differentiate pulmonary bleeding from gastrointestinal bleeding

An important diagnostic step in hemoptysis is to exclude sources from the nasopharynx, nose, larynx, and upper GI tract. The patient may swallow blood, which complicates the diagnosis.

• Pulmonary bleeding: blood is bright red, foamy (due to air), coughed up, and has an alkaline reaction. In lobar pneumonia, «rusty sputum» appears; in bronchogenic carcinoma (in late stages), sputum resembles «raspberry jelly».
• GI bleeding: presents with vomiting (hematemesis). The blood is dark, often resembling «coffee grounds» (the result of hydrochloric acid acting on hemoglobin), has an acidic reaction, and may contain food particles. Melena (black tarry stool) appears later. In Mallory-Weiss syndrome, vomiting of bright red blood occurs after repeated episodes (characteristic of young people abusing alcohol).

Types of hemorrhage and blood collections

Morphologically, hemorrhages are divided into interstitial and cavity hemorrhages.

Tissue hemorrhages:

• Hematoma — an accumulation of clotted blood forming a cavity (tissue is destroyed and replaced by blood).
• Hemorrhagic infiltration — blood impregnates tissues without destroying their structure.
• Ecchymosis (bruise) — a flat hemorrhage in the skin or mucous membranes.
• Ecchymoma — a bruise larger than 2 cm (if larger than 10 cm, it is a sign of severe hemorrhagic syndrome).
• Petechiae — pinpoint hemorrhages.
• Hemorrhagic purpura — multiple coalescing petechiae.

Collections in cavities:

• Hemothorax — blood in the pleural cavity; can be complicated by aseptic hemopleuritis or empyema.
• Hemopericardium — blood in the pericardial sac (risk of cardiac tamponade).
• Hemarthrosis — blood in a joint (specific for hemophilia).
• Hemoperitoneum — blood in the peritoneal cavity.

Terminology of bleeding by localization

Specific terms are used to describe the source of blood loss:

• Melena — black stool, a marker of upper GI bleeding (must be distinguished from pseudomelena caused by iron or bismuth preparations).
• Hematochezia — bright red blood in the stool. Indicates lower GI pathology (tumors, colitis) or hemorrhoids (arterial blood due to glomus anastomoses).
• Hematuria — presence of blood in the urine.
• Metrorrhagia — uterine bleeding.
• Cephalohematoma — subperiosteal hemorrhage on the skull in newborns.

Differentiation of hemorrhagic syndrome types

The clinical picture allows for a preliminary determination of the type of hemostatic disorder:

1. Microcirculatory (thrombocytic): ecchymoses appear asymmetrically, are painless, and joints are not affected.
2. Hematomal (coagulopathic): painful hematomas, hemarthroses, bleeding does not occur immediately after trauma or surgery. A thorough family history for hereditary coagulopathies (hemophilia) is mandatory.
3. Vasculitic-purpuric: symmetrical raised rash (mostly on extensor surfaces), may be combined with abdominal pain, joint pain, and kidney involvement.

Class and exam questions

What else to study on this topic

• Assessment of blood loss severity and risks (PE, pulmonary infarction)
• General morphological signs of acute and chronic blood loss at autopsy
• Hereditary thrombocytopathies (Glanzmann thrombasthenia)
• Classification of thrombocytopathies with thrombocytopenia by platelet size
• Rare hereditary coagulopathies (factor II, VII, X deficiency)

Other topics in the "Additional Topics" section

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