Tuesday, February 23, 2016

Hidden bleeds

So this is what my fellow asked me today: Say, there is a patient whose hemoglobin is dropping, dropping, dropping and he has barely any significant signs or symptoms.. Besides the GI tract, where else can you have a significant bleed which can be hidden? There are three such places.

Guess before you read the answer! :D

1. Retroperitoneal bleeds can be a source of significant yet occult blood loss.

2. A hematoma in the thigh can be surreptitious.

3. A hematoma in the upper arm, especially in obese patients can be hard to find.

The brain and the lung are limited in space, so it's hard to have massive bleeds in these areas without having symptoms.

I thought it was kinda cool to know so I shared it with you guys. Keep these things in mind while evaluating a patient with occult blood loss, especially in patients with bleeding diathesis.

That's all!



  1. Can it not be a bleed into peritoneum from a uterine vessel after c-section..?

    1. It can be... But a bleed into the peritoneum will cause peritoneal irritation, leading to localized or generalized pain in the abdomen and/or tenderness/rigidity. So it isn't always "hidden" and after a drop in 1 or 2 g/dL of hemoglobin, you will definitely diagnose it.

      In retroperitoneal bleeds, however, the hemoglobin might drop 6-8 g/dL and you still can't find the source.

      (PS: The list of differentials for peritoneal hemorrhage is huge.)

    2. Here's the differentials for you, in case you were wondering! :D

      Ectopic pregnancy
      Ruptured ovarian cyst
      Uterine leiomyoma/leiomyosarcoma
      Ovarian granulosa cell tumor
      Ruptured corpus leuteum cyst
      Hyperemesis gravidarum
      Spontaneous uterine rupture

      Chronic myelomonocytic leukemia
      Infectious mononucleosis
      Spontaneous splenic rupture
      Spontaneous rupture of splenic vein
      Torsion and rupture of wandering spleen
      Primary splenic angiosarcoma

      Peliosis hepaticus
      Hepatic adenoma/adenomatosis
      Hepatocellular carcinoma
      Primary hepatic angiosarcoma
      Metastatic cancer
      Focal nodular hyperplasia
      Biliary Ruptured cholangiocarcinoma
      Transhepatic rupture of gallbladder

      Ruptured cystic artery pseudoaneurysm
      Ruptured splenic artery aneurysm
      Segmental mediolytic arteriopathy

      Mixed cavernous-capillary hemangioma

      Meckel’s diverticulitis

      Ruptured pseudocyst

      Ruptured benign solitary fibrous tumor


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