BLEEDING DISORDERS

By

Diaa Ahmed Elsaied

Lecturer OMFS Minia University

Leukopenia :

Deficient WBC , Decrease of neutrophils is most common etiology .

Physical finding are increased risk microbial infection.

Increased risk of fungal infection.

Management include :

-- Prophylactic Antibiotic.

Elevated percentage of immature WBC in peripheral circulation.

It is cancer of the WBCs that affects the bone marrow and circulating blood. It involves exponential proliferation of a clonal myeloid or lymphoid cell.

Symptoms includes:

Nausea – Fever – Weight Loss

Fatigue – Malaise - Epistaxix

Liver or spleen enlargment Bone pain & tenderness

Oral manifestation includes:

Gingival Enlargement & ulceration

Pain Erythema & oral infection

The cause of leukemia is unknown

Increased risk is associated with large doses of ionizing

radiation, certain chemicals(benzene), and infection with

specific viruses [EPV] and human lymphotropic virus

[HTLV]-1

Smoking & exposure to electromagnetic

Genetic factors may cause cytogenetic abnormalities that

affect transcriptional cascades of myeloid precursor cells.

Acute leukemia

Result from accumulation of immature , functionless WBCs in the marrow & blood

1. Acute myeloid leukemia (AML)

2. Acute lymphocytic leukemia (ALL)

Chronic leukemia

Have slower onset which allows production of larger numbers of more mature, functional cells

1. Chronic myeloid leukemia (CML)

2. Chronic lymphocytic leukemia (CLL)

Bone marrow test

1. Bone marrow aspiration :

Remove a liquid marrow sample

2. Bone marrow biopsy

Lumbar puncture:

Removes a small amount of

cerebrospinal fluid (CSF) from the space around the spine

Chemotherapy

The main treatment for many kinds of leukemia

It has 3 phases:

1- Induction

2- Consolidation

3- Maintenance

Radiation therapy

To prevent leukemia from spreading to, or treat leukemia that has spread to, the central nervous system (CNS)

Bone marrow transplant

LEUKEMIA

Anemia is a decrease in the total amount of red blood cells (RBCs) or hemoglobin in the blood, or a lowered ability of the blood to carry oxygen.

Laboratory definition:

Reduction in haemoglobin concentration

below normal

WHO criteria:

Males Hgb <13 gm/dl,

Females Hgb <12gm/dl

Symptoms:

Fatigue Weakness Dyspnea Palpitation

Headache Dizziness Angina Tinnitus

Signs:

Pallor Tachycardia Cardiac Failure

Medical & family history & perform a physical exam.

Complete blood count (CBC):- A CBC is used to count the number of blood cells in a sample of your blood. For anemia the levels of the red blood cells contained in the blood (hematocrit) and the hemoglobin in the blood is interested.

Tests for internal bleeding:- To ensure that internal bleeding is causing anemia, may also perform an endoscopy. These test can help identify sources of gastrointestinal bleeding.

Treatments for anemia depend on cause and severity. Vitamin supplements given orally (folic acid or vitamin B12) or intramuscularly (vitamin B12) will replace specific deficiencies.

Anemia treatment depends on the cause.

a) Iron deficiency anemia

b) Vitamin deficiency anemia

c) Anemia of chronic disease

d) Aplastic anemia

e) Anemia associated with bone marrow disease

f) Hemolytic anemia

g) Sickle cell anemia

Iron deficiency anemia:- Treatment for this form of anemia usually involves taking iron supplements & making changes to your diet.

• Diet as red meat, dark green leafy vegetables, dried fruits, nuts, iron-fortified cereals.

Vitamin deficiency anemia:- Treatment for folic acid & B-12 deficiency involves dietary supplements & increasing these nutrients in diet.

•If your digestive system has trouble absorbing vitamin B-12 from the food you eat, you may need vitamin B-12 shots.

Platelets Phase:

Platelet Count

Bleeding Time (BT)

Platelets Funtion Analyzer (PFA)

Coagulation Phase:

Prothrombin Time (PT)

Partial Thromboplastin Time (PTT)

Thrombin Time (TT)

NORMAL 100,000 - 400,000 CELLS/MM3

,

< 100,000 Thrombocytopenia

50,000 - 100,000 Mild Thrombocytopenia

< 50,000 Sever Thrombocytopenia

Provides Assessment Of Platelet Count & function (Quantitative & Qualitative)

NORMAL VALUE

2-8 Min

Quntative lab test for platelets function & avoid variability of BT

Normal < 193 s

Measures Effectiveness of the Extrinsic Pathway

Mnemonic - PET

NORMAL VALUE

11- 14 SECS

Measures Effectiveness of the Intrinsic

Pathway

Mnemonic - PITT

NORMAL VALUE

27 – 38 SECS

Time for Thrombin To Convert

Fibrinogen Fibrin

A Measure of Fibrinolytic Pathway

NORMAL VALUE

9-13 SECS

Dental management of the medically compromised patient

PT, aPTT, TT, BT History bleeding problem

BT, aPTT Aspirin therapy

PT Coumarin therapy

aPTT Renal dialysis (heparin)

BT – PT Possible liver disease

BT Chronic leukemia

PT Long term antibiotic therapy

BT Vascular wall alteration

TT Cancer (fibrinogenolysis)

TT PT PTT BT Platelet count Condition

- + + + + Aspirin therapy

- ++ ++ - - Coumarin therapy

- - ++ + + Heparin therapy

++ ++ ++ + + Liver disease

- - - + + Leukemia

++ ++ ++ - - Long term antibiotic

- - - + - Vascular wall defect

- - - ++ ++ Thrombocytopenia

- - ++ - - Hemophilia

++ + + - - Fibrinogenolysis

- normal, + may be abnormal, ++ abnormal

GOOD THOROUGH MEDICAL HISTORY

A PHYSICAL EXAMINATION

SCREENING CLINICAL LAB TESTS

EXCESSIVE BLEEDING FOLLOWING SURGICAL

PROCEDURE

Family HX

Personal HX

Medications

Past & Present Illness

Spontaneous Bleeding

FIVE DRUGS THAT INTERFERE WITH HEMOSTASIS

ASPIRIN

ANTICOAGULANTS

ANTIBIOTICS

ALCOHOL

ANTICANCER

Petechiae & Ecchymosis

Gingival Hyperplasia

Spontaneous Gingival Bleeding

Ulceration of Oral Mucosa

Lymphadenopathy

LOW RISK

Patients with No Hx of Bleeding Disorders

Normal Laboratory Results

MODERATE RISK

Patients on Chronic Oral Anticoagulant

Therapy. PT is 1.5 - 2 Times Control Range

Patients on Chronic Aspirin Therapy

HIGH RISK

Patients with Known Bleeding Disorders

Patients without Known Bleeding Disorders

Who Have Abnormal Laboratory Results

LOW RISK PATIENTS

Normal Protocol

MODERATE RISK PATIENTS

Anticoagulants - Consult Physician

Aspirin Therapy - BT, Consult Physician

HIGH RISK PATIENTS

Close Coordination with Physician

Hospitalization (Platelet Transfusion)

(Factor Replacement)

(Vit K Therapy)

(Dialysis)