Oh No, I Have Blood on My New Shirt!

Nosebleeds are common and are usually from trauma outside the nose or inside the nose. If you nose itches inside, consider putting a little petroleum jelly on a cotton swab and coating the itchy area. This is a common problem when the seasons change and there is more pollen in the air.

To avoid getting it in your lungs, it is best to use the smallest amount possible and don’t use it unless you are not going to lay down for 2 hours, and don’t sniff it up your nose. We had a patient last year with lipoid pneumonia and she is very ill and may not live long. Nose bleeds can come out the front or back of the nose. If it persists for >20 minutes then you may need to go to the emergency room. Most people will stop bleeding and clot in under 10 minutes. If it is from the front, then gently squeeze the soft part of your nose and lean forward for at least 10 minutes.

Excessive bleeding can happen if there are problems with the three parts of coagulation: the tissue, the clotting factor function, and the platelets.

Tissue: You will notice that older people seem to bruise easily and have thin skin. “Paper thin,” is used to describe the skin of some very old people. Their blood vessels are weaker, especially on the sun-exposed areas. They lack some of the collagen and elastin that was damaged by the sun and they decrease with age.

Clotting factors: These are made by the liver and are dissolved; when they are activated by an injury, they form fibrous strings holding a clot full of platelets and red cells together and actually can contract to tighten the clot to close the hole or tear.

Platelets: These are tiny fragments of large cells that rush to sites of injury and try to physically plug up the holes. They release chemicals that help the clotting process.

There can be abnormalities in each of these three components. I have explained the tissue abnormalities of aging. There are also rare genetic problems that weaken the tissue.

Clotting factor problems can be from medications. When it is from genetic defects, it is called hemophilia.

Low Platelets can be from medications too. But it is more common in those with cirrhosis from chronic alcohol use or untreated chronic hepatitis, usually B or C. The blood cannot flow well through the scarred liver (on the left) so the pressure backs up and enlarges the spleen (on the right). The spleen keeps a reserve of platelets for emergencies, but now has much more room for them so the amount in the blood is much lower.

Sometimes the platelets don’t work well. We say they are less sticky. Aspirin is given to make platelets this way so that we can prevent strokes and heart attacks, especially those at high risk for these or those who have had one or more of them before. So before a procedure with sharp instruments, the medical provider will have you stop your anti-platelet drug several days early.

Cirrhosis from alcohol or hepatitis is a triple threat. The platelets are hung up in the spleen, the fibrotic liver doesn’t make the clotting factors well, and the pressure in the veins in the abdomen, from the liver being fibrotic and not letting the blood flow through it easily, causes varices or varicosities. These are swollen veins which can bleed; hemorrhoids below, and esophageal varices above. People tend to call 911 when they bleed from below. When they bleed from above, it may be hours before they notice, especially when they are asleep. They may vomit up huge amounts of blood. A good number of cirrhotics die a bloody death—messy but not painful.

Cirrhosis sneaks up on people. There may not be any symptoms or warning till it is far advanced so gay men should be checked routinely for hepatitis B and C as well as HIV and sexually transmitted infections.

The first sign of cancer can be bleeding. Cancers of the white cells or the lymph system may produce so many cancerous cells in the bone marrow that the platelet forming cells are crowded out.

If you have clotting or platelet problems, then avoiding sharp objects and trauma is a great idea. I have seen some major bleeding or bruises from car crashes in these patients. You should probably give up skydiving or watching sharks from a shark cage.

Abnormal bleeding can be hidden. If it comes from your rectum, mouth, nose, lungs, in your head, or in the urine, it gives a warning. If you bleed into your abdominal cavity (outside the intestine), or deep in your thigh, what is causing the pain or swelling may not be so obvious.

We check a CAT scan of the head if we want to make sure that there is no bleed in there. The blood may compress the brain against the bones of the cranium, killing large areas of the brain. Obviously this is an emergency and we arrange for a neurosurgeon to evaluate the patient.

So, my friends, take good care of yourselves, be safe, get checked periodically.