UNUSUAL BLEEDING & BRUISING

The only bleeding which is strictly "normal" is vaginal loss in women during menstruation and in the immediate postnatal period. Other bleeding which is common enough to be within normal experience is occasional bleeding from the nose, from the gums, from the anus and, of course, from cuts and skin lesions - though this is never strictly normal it may often signify only minor problems though occasionally it does signify serious disease. Similarly bruising is common but may signify an important health problem. When should one be concerned?

First and foremost one should be guided by what seems normal and appropriate. A bruise after a hard knock is normal but bruises appearing for no apparent reason (especially if this is new and unusual for you) are not and need to be checked out quite promptly as the blood clotting mechanisms may not be working correctly. Similarly prolonged bleeding after trivial skin trauma may signify clotting problems. Whilst medication (especially aspirin and warfarin) may account for this it can also be due to problems with the manufacture of blood cells, especially the minute platelets which help blood clots to form. Heavy periods (flooding), heavy frequent nosebleeds and blood in the urine may also indicate blood clotting defects. A trace of blood on the toilet paper after the painful passage of a hard stool is probably not too concerning but if it happens frequently or is heavy or there is no obvious precipitating cause then it needs checking.

Set out below is a list of sites of bleeding and possible causes and the urgency to have the problem checked.

• Vaginal bleeding is not normal if it occurs between periods, after intercourse, before the onset of periods (menarche) or after the menopause. Periods may be irregular in frequency, duration and/or the heaviness of the loss - especially just after the menarche and leading up to the menopause. Some women have irregular loss over long periods of time. If an established pattern suddenly changes it needs checking out. Additional factors suggesting a problem are pain and discharge and the presence of these make a visit to the doctor essential but are not always present in serious disease.
• Blood in the urine occurs in two situations:
  • With pain and frequency of urine. Often this is associated with a urine infection but this needs confirmation with a urine culture and it needs treating.
  • Without pain. More worrying as possible causes include kidney disease and tumours. MUST be checked out.
• Blood from the anus. After a hard stool is passed there may be some local trauma and soreness around the opening. Also piles may be present and these can often be felt coming down as a soft swelling of the tissues. In both cases there may be some bleeding on the toilet paper. If this keeps occurring it needs investigation anyway, even if the cause seems obvious, but slight traces of blood associated with soreness and occurring infrequently can affect anybody. Again bleeding not associated with local soreness could be due to more serious disease such as colitis, a polyp or a tumour. If there is acute diarrhoea the cause may be a bowel infection. Whatever the cause turns out to be the bleeding should be reported to us. (Note, bleeding from the stomach which finds its way down to the anus is TARRY BLACK [called melaena] and has a rather offensive smell quite different from normal stool - it always  merits being reported immediately as blood loss may be significant and the cause important to discover. N.B. iron preparations colour the stool black but there is a slight greenish tinge in contrast to melaena which is truly black.)
• Vomiting blood.  
  • Bright red blood may be coming from the mouth, nose, throat or gullet (oesophagus). After prolonged retching the lining of the gullet may be torn and bleed. Throat infections and nosebleeds may also be the source. Any significant amount of bleeding (i.e. more than a few streaks), recurrent bleeding or bleeding without an obvious cause needs further investigation.
  • Altered blood. Blood from the stomach (whether it arises there or comes from somewhere else such as the duodenum or has been swallowed) is BLACK. This is because of exposure to the acidic digestive juices in the stomach. Usually it curdles into granules which resemble coffee grounds dispersed in water. This type of vomit always needs reporting.
• Coughing blood. The causes range from the trivial such as a viral throat to important causes such as chest infections, clots on the lung and tumours. Unless the cause is obvious such as a very sore throat or a nosebleed it always warrants checking out, even if the amount is small, as is often the case.
• Nosebleeds (epistaxis). These are relatively common.Unless this is due to a punch or blow to the nose it is usually associated with a "cold" or upper respiratory infection, in which case the bleeding is from the lining of the cartilage that separates the nostrils. This often looks quite inflamed. Firm pressure squeezing the soft part of the nose between forefinger and thumb usually stops it in about 10 minutes (sit upright with the head slightly foreward at the same time). If repeating this twice in succession for 10 minutes each time is ineffective ring for advice - either ourselves or NHS Direct on 0845 4647 (if the bleeding is very heavy go directly to Accident and Emergency). In two particular situations the nosebleeds may be more worrying: patients with high blood pressure and hardened arteries may get bleeding from the back of the nose which is usually heavy and difficult to staunch at home. Also, impaired clotting (either due to problems with the blood or to medication such as Warfarin or aspirin) can cause heavy nosebleeds which are unlikely to stop on their own. In both these situations the problem may be well known and understood or it may be unexpected and out of the blue. Whilst occasional nosebleeds that stop easily are almost part of normal life, heavy nosebleeds that won't stop are a genuine emergency and repeated nosebleeds occurring over a period of several days may need reviewing in surgery.
• Bleeding from the ears is never normal. If it follows a blow to the head it may well indicate a skull fracture and is consequently an emergency. Otherwise it probably indicates local infection which needs prompt attention. (Poking the ears with a sharp, or even a blunt, object can make them bleed very easily because there is only thin tissue overlying the bone and is not a good idea at all).

Return