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GASTRIC AND INTESTINAL FUNCTION A.

Evaluation of Gastric Acid Secretion Gastric acid secretion is evaluated in a quantitative manner by measurement of acid in timed collections of gastric contents or in an indirect manner by the Diagnex-blue test. In the Hollander test, gastric acid secretion is measured for the purpose of evaluating therapy for peptic ulcers. 1. Clinical Correlation of Gastric Acid Secretion Rates Acid secretion rate is determined from measurement of acid in specimens collected before (BAO) and after (MAO) stimulation (see procedural details). Gastric acid secretion is subnormal or absent (achlorhydria) in cases of chronic fundal gastritis (accompanied by pernicious anemia). Gastric ulceration in the absence of acid output suggests carcinoma since some acid must be present for peptic ulcers to develop. Acid output is low normal to normal in cases of chronic antral atrophic gastritis. The fundus makes acid but is poorly stimulated because gastrin elaboration by the atrophic antrum is lacking. Gastric peptic ulcers are typically associated with this degree of acid output. Duodenal peptic ulcer is associated with higher than normal acid secretion rates. Gastric acid output is greatest in the Zollinger-Ellison syndrome.

2. The Hollander Test The purpose of the test is to evaluate the outcome of surgical treatment (gastrectomy and vagotomy) for peptic ulcers. Acid is measured in gastric fluid collections before and after inducement of hypoglycemia by insulin administration. Hypoglycemia stimulates gastric acid secretion via the vagal nerves and if bilateral vagotomy is complete, MAO increases less than 2 mEq/hr over the BAO.

3. The Diagnex-Blue Test The test provides an indirect indication of adequate gastric acid secretion A diagnostic pill, the active ingredient of which is a colored dye bound to a cation exchange resin, is administered orally. The dye is released from the ion exchange resin in the stomach only if there is adequate acid present. Released dye is absorbed by the intestines and is consequently excreted in urine. The finding of sufficient dye in a urine specimen provides a definite indication of adequate gastric acid secretion and rules out achlorhydria. Low results are equivocal and direct measurement of acid in gastric fluid collections is required to establish achlorhydria.

B. Serum Gastrin - for diagnosis of the Zollinger-Ellison syndrome. Serum gastrin concentration is determined by radioimmunoassay. Highest serum gastrin concentrations are found in cases of the Zollinger-Ellison syndrome. High serum gastrin concentrations are also found in cases of fundal atrophic gastritis with achlorhydria because of the lack of feedback inhibition. serum gastrin (pg/ml) < 500 low to normal 300 - 500

Condition

normal antral gastritis duodenal ulcer

fundal gastritis

300

- 60,000

Z.E. syndrome

3,500 - 60,000

C. Detection of blood in the stool The presence of blood in the stool (hematochezia) may result from ulcers or from carcinoma anywhere along the GI tract. If present in sufficient quantity, the blood will be visibly evident as black colored stool from upper GI bleeding (melena) or red colored from lower GI bleeding. "Occult" blood is detectable by laboratory testing using filter paper strips impregnated with guaiac, which turns blue in the presence of peroxidase activity (hemoglobin). About 20 ml of blood must be present to obtain a positive result.

D. The Schilling test - to evaluate vitamin B12 malabsorption. A consequence of vitamin B12 deficiency is macrocytic anemia and characteristic megaloblastic changes of the myelocyte precursors in bone marrow aspirates. Folate deficiency has the same consequence. Vitamin B12 deficiency is established by finding low serum vitamin B12 concentrations (measured by radioimmunoassay). Vitamin B12 deficiency may be due to pernicious anemia (lack of gastric secretion of intrinsic factor from fundal gastritis) or to intestinal malabsorption or, rarely, to dietary deficiency. Results from the two stage Schilling test provide a differential diagnosis. .The test involves evaluation of absorption of two orally administered test doses of radioactive labelled vitamin B12 on the basis of measuring radioactivity in a urine specimen collected for five hours. The first test dose (1st stage) is administered alone and the 2nd test dose (2nd stage, three days later) is administered along with intrinsic factor. Typical results are shown in the accompanying table.

Results Condition 1st Stage With normal vitamin B12 absorption, the test dose will be found to be absorbed, on the basis of finding sufficient radioactivity in the urine specimen, without (1st stage) and with (2nd stage) exogenously administered intrinsic factor. Normal results will be found in cases of vitamin B12 deficiency from chronic dietary lack. In cases of pernicious anemia, malabsorption found in the first stage is ameliorated when intrinsic factor is given in the second stage of the test. In cases of intestinal disease, the test dose is malabsorbed in both stages. normal dietary deficiency intestinal disease pernicious anemia absorption 2nd Stage absorption

absorption

absorption

malabsorption malabsorption

malabsorption absorption

E. Tests for steatorrhea Absorption of dietary fat requires bile salts, pancreatic lipase, formation of bile salt/fatty acid micelles and intestinal absorption. Malabsorption of fat may result from bile duct obstruction, pancreatic in sufficiency or intestinal disease. 1. Indirect indications from decreased absorption of fat soluble vitamins:

decreased vitamin D absorption ==> negative calcium balance ==> secondary hyperparathyroidism ==> osteomalacia decreased vitamin K absorption ==> prolonged prothrombin time ==> susceptibility to hemorrhage decreased carotene absorption ==> decreased serum levels determined from O.D. measurement of organic solvent extract

2. Microscopic examination of neutral fat stained stool smear. 3. Quantitative fecal fat determination on a 72 hr. stool specimen with 100 g/day dietary fat: - Normal - Equivocal - Steatorrhea < 5 g/day 5- 7 >7

4. Note: Total fat (including both triglyceride and free fatty acid) is measured, so that steatorrhea from intestinal or pancreaic origin is not distinguished. Determination of the fatty acid/triglyceride composition of a stool specimen might conceivably differentiate pancreatic insufficiency and intestinal malabsorption as the cause, but bacterial lipolytic activity precludes the differentiation. Nevertheless, the quantitative fecal fat determination provides the most definitive criterion for steatorrhea. 5. Measurement of absorption of 125I-labeled oleic acid and 131I-labeled triolein Procedure: A diagnostic 'fat pill' containing both 125I-labeled oleic acid and 131I-labeled triolein is administered orally. (Use of different isotopes for triolein and oleic acid allows measurement of both isotopes in the same sample. Use of the same isotope would require that the tests for triolein and oleic acid uptake be performed on different days.) A blood specimen is drawn 4 hours later and the 125I and 131I are counted simultaneously. 125I radioactivity reflects free fatty acid absorption and 131I radioactivity reflects triglyceride absorption as illustrated in the figure below.

Whereas absorption of triolein is dependent on pancreatic lipase, oleic acid absorption is independent of pancreatic exocrine function. Normal or near normal absorption of labeled oleic acid along with abnormal triolein uptake, as in the figure to the right, suggests impaired pancreatic function. Failure of absorption of both triolein and oleic acid indicates fat malabsorption of nonpancreatic origin.

F. D-Xlose Test (for evaluation of monosaccharide absorption) D-xylose is a monosaccharide which is normally readily absorbed by the intestine, is poorly metabolized and is not reabsorbed from the glomerular filtrate. Following oral administration of a test dose of a solution of the monosaccharide, a blood specimen is collected 2 hours later and a urine specimen is collected for five hours.(see procedural details) Intestinal malabsorption is reflected in a low amount of D-xylose in the 5 hour urine specimen. (The blood specimen result is important only in cases of renal disease.)

G. Disaccharidase deficiencies Disaccharidase deficiencies are a cause of colic (intestinal discomfort with vomiting and/or diarrhea) in infants and are not uncommonly acquired in adults. Lactase or sucrase is most commonly deficient; isomaltase deficiency is rare.

Although the enzyme deficiencies may be evaluated by administration of the disaccharide followed by serum glucose determinations over a two-hour period (tolerance tests) or by assaying biopsy tissue for enzyme activity, the most practical evaluation is by dietary deletion.

DISORDERS OF ERYTHROCYTE METABOLISM Congenital nonspherocytic hemolytic anemia (CNSHA) traditionally includes erythrocyte disorders not due to defects of the red cell membrane or hemoglobin, immune-mediated disease, or other diseases such as paroxysmal nocturnal hemoglobinuria. CNSHA is a heterogeneous group of disorders associated with various metabolic abnormalities of the erythrocyte, including enzymopathies of glucose, glutathione, and nucleotide metabolism. Like the membrane disorders, clinical, biochemical, and genetic heterogeneity are typical within the enzymopathies. Hemolysis may develop as a result of either enzyme or antioxidant deficiency or dysfunction (e.g., abnormal substrate or cofactor binding), altered activation or inhibition characteristics, or decreased stability or specific activity. Peripheral blood smears in CNSHA, with the exception of pyrimidine 5-nucleotidase deficiency, are unremarkable. Osmotic fragility of fresh erythrocytes is normal. Response to splenectomy is variable. Inheritance is heterogeneous. A thorough family history is important and may be of assistance in determining the diagnosis. Manifestations of the metabolic defect are usually confined to the erythrocyte but may occasionally involve nonerythroid cells. Definitive diagnosis of metabolic abnormalities of the red cell depend on qualitative or quantitative assays of specific enzyme activity or identification of the specific genetic mutation by DNA analysis. Results of enzyme assays should be interpreted with caution because (1) they only sample surviving red cells in the peripheral blood, and the metabolic milieu of these cells is not necessarily comparable to cells already hemolyzed; (2) in vitro enzyme assay conditions may not accurately reflect the in vivo environment; (3) transfusions before the assay may obscure the underlying metabolic defect, and (4) leukocyte contamination may lead to spurious results. Finally, average enzyme activity may not accurately reflect activity in subpopulations of erythrocytes. This is particularly true when there is reticulocytosis, which may yield artificially elevated mean enzyme activity owing to higher enzyme levels found in reticulocytes. Disorders of the Embden-Meyerhof Pathway Defects of the Embden-Meyerhof pathway are inherited in an autosomal recessive fashion, and usually hemolysis is seen only in homozygotes or compound heterozygotes. Heterozygotes, whose erythrocytes contain less than normal amounts of mutant enzyme, are clinically normal. An exception is phosphoglycerate kinase deficiency, an X-linked disorder with hemolysis found only in males. In this group of disorders, hemolysis is chronic, is not typically influenced by drugs or other inciting agents, and is attributed to insufficient levels of erythrocyte ATP. Splenomegaly from trapping of mutant erythrocytes is common. The hostile splenic environment contributes to the shortened erythrocyte life span. When performing specific diagnostic enzyme assays, measurement of glycolytic intermediates may assist in diagnosis because concentrations of intermediates is increased upstream of a defect and decreased downstream of a defect.

PYRUVATE KINASE DEFICIENCY Pyruvate kinase (PK) deficiency accounts for approximately 90% of inherited defects of the Embden-Meyerhof pathway and is the second most common inherited erythrocyte enzymopathy associated with anemia after glucose-6-phosphate dehydrogenase (G6PD) deficiency (see later). PK deficiency is found worldwide, but it is most common in individuals of northern European descent. Pathobiology PK catalyzes the conversion of phosphoenolpyruvate (PEP) to pyruvate, generating ATP. Deficient or defective PK leads to decreased levels of erythrocyte ATP, disturbing many cellular processes such as signaling and maintenance of water and ion content, leading to energy failure and dehydration. Upstream catabolites accumulate in the erythrocyte, including 2,3-DPG, which shifts the oxygen dissociation curve to the right, enhancing tissue oxygenation and ameliorating some of the physiologic effects of anemia. Early PK-deficient reticulocytes retain the ability to utilize oxidative phosphorylation to produce ATP, bypassing their defect. This ability is lost as reticulocytes mature and is markedly dampened in the hypoxic environment of the spleen. PK deficiency is inherited in an autosomal recessive manner. Affected individuals are homozygous or compound heterozygotes for PK defects. Heterozygotes are clinically normal or exhibit very minimal hemolysis. Clinical Manifestations Clinical manifestations in PK deficiency are heterogeneous, ranging from asymptomatic to transfusion-dependent hemolytic anemia. More severely affected patients present in infancy or early childhood with anemia, jaundice, and splenomegaly. Occasionally, patients may escape detection until later in life when complications related to anemia and chronic hemolysis occur such as cholelithiasis or aplastic crisis or when the diagnosis is made during evaluation of the patient for another condition. Diagnosis Peripheral blood smear demonstrates normocytic, normochromic erythrocytes, sometimes with spiculations (Fig. 1644A). Poikilocytes and acanthocytes may also be seen. Reticulocytosis is common. Osmotic fragility of fresh erythrocytes is usually normal. Occasional patients exhibit a population of osmotically fragile cells after incubation. Figure 164-4 Peripheral blood smears in erythrocyte enzymopathies. A, Pyruvate kinase deficiency NADH fluorescence under ultraviolet light is a commonly used screening test for PK deficiency. PEP and NADH are mixed with the patients blood, incubated, and spotted on filter paper, and fluorescence is measured. Direct enzyme assay, which uses PEP as substrate for PK, can be performed on leukocyte-free hemolysate to confirm abnormal fluorescence tests. Leukocytes must be carefully depleted from the samples because they contain over 300 times the PK activity of erythrocytes. TREATMENT Most patients require only expectant management, with only rare transfusions, such as during an aplastic episode. In severe cases, patients may be transfusion dependent. In these cases, splenectomy typically lessens hemolysis and ameliorates the anemia. After splenectomy, some patients develop marked reticulocytosis, up to 50 to 70%. This paradoxical reticulocytosis is attributed to increased reticulocyte survival after removal of the hostile splenic environment. OTHER DISORDERS OF THE EMBDEN-MEYERHOF PATHWAY

Other abnormalities of the Embden-Meyerhof pathway have been described. Hexokinase deficiency is quite uncommon, with great phenotypic variability in reported cases. Severely affected patients have suffered from anemia beginning in infancy and may require blood transfusion. Glucose phosphate isomerase (GPI) deficiency is the third most common hemolytic enzymopathy. GPI deficiency usually presents in infancy or early childhood with moderate to severe hemolytic anemia. Phosphofructokinase deficiency may involve erythrocytes, muscle, or both. Presentation is usually in adolescence with exertional myopathy. Hemolytic anemia has been described in isolated cases of 2,3bisphosphoglycerate mutase deficiency and phosphoglycerate kinase deficiency. Disorders of Nucleotide Metabolism Mature erythrocytes lack the ability to synthesize purine and pyrimidine nucleotides de novo. However, they are able to form some nucleotides through salvage pathways. PYRIMIDINE 5-NUCLEOTIDASE DEFICIENCY Pyrimidine 5-nucleotidase (P5N) degrades the pyrimidine nucleotides of RNA to cytidine and uridine, which can diffuse out of the cell. When P5N is deficient, nondiffusible, partially degraded RNAs accumulate, leading to the marked basophilic stippling characteristic of P5N-deficient erythrocytes (seeFig. 164-4B). These accumulated pyrimidine nucleotides inhibit the transport of GSSG out of red cells, leading to high levels of erythrocyte glutathione. Clinically, there is mild to moderate hemolytic anemia and splenomegaly. The etiology of the hemolysis remains cryptic. Typically, splenectomy does not ameliorate the hemolysis and anemia. Disorders of the Hexose Monophosphate Shunt (Pentose Phosphate Pathway) and Associated Pathways Disorders of the HMP shunt or of the glutathione metabolic pathways (see Fig. 164-3) compromise the ability of the red cell to respond adequately to oxidative stress. In the normal erythrocyte, GSH detoxifies oxidants produced by various agents and infection. In G6PD-deficient erythrocytes, because of the inability to generate NADPH, GSH levels are inadequate, leaving the cell susceptible to oxidant stress. Oxidation of hemoglobin sulfhydryl groups leads to the production of methemoglobin and intracellular hemoglobin precipitates called Heinz bodies. Heinz bodies (see Fig. 1644D), usually visualized on peripheral blood smears with supravital stains such as methyl violet, attach to and damage the erythrocyte membrane. They induce clustering of immunoglobulins and band 3 protein, marking the erythrocyte for opsonization by phagocytes and eventual removal from the circulation. Heinz bodies are pitted from circulating cells by the spleen and are commonly seen on smears of patients after splenectomy. Bite cells, erythrocytes with localized invaginations, possibly at the site of Heinz body injury or removal, are seen during acute hemolytic episodes. In addition to damage from Heinz body formation, GSH-deficient erythrocytes also undergo peroxidation of membrane phospholipids and oxidative cross-linking of spectrin, decreasing membrane deformability and further promoting splenic trapping. GLUCOSE-6-PHOSPHATE DEHYDROGENASE DEFICIENCY G6PD deficiency is the most common inherited disorder of erythrocyte metabolism, affecting more than 400 million people worldwide. The high prevalence of G6PD deficiency is thought to be due to genetic selection because G6PDdeficient erythrocytes have a selective advantage against invasion by the malaria parasite Plasmodium falciparum. Epidemiology and Pathobiology G6PD is the initial and rate-limiting step in the HMP shunt (see Fig. 164-3), which converts NADP into NADPH. NADPH is required for the generation of glutathione, a critical constituent in the prevention of oxidative damage to the cell. G6PDdeficient patients may develop acute hemolytic anemia after exposure to oxidative stress. Although G6PD is a ubiquitous

enzyme, erythroid cells are particularly susceptible to oxidative stress because the HMP shunt is their only source of NADPH. Hundreds of G6PD variants have been described, but only a few are common. Variants are classified on the basis of biochemical characteristics, electrophoretic mobility, ability to use substrate analogue, Km for NADP and G6PD, pH activity profile, and thermal stability. The normal enzyme, GdB, is present in 99% of white Americans and 70% of African Americans. A normal variant, GdA+, found in 20% of African Americans, has a faster electrophoretic mobility than GdB. GdA, the most common variant associated with hemolysis, is found in about 10% of African Americans and in many Africans. GdA has decreased catalytic ability compared with GdA+. GdMed, the second most common variant associated with hemolysis, is common in the Mediterranean area, in India, and in southeast Asia, with a prevalence of up to 5 to 50%. GdMedexhibits markedly decreased catalytic activity. GdCanton, a variant common in Asian populations, produces a clinical syndrome similar to GdA. GdB activity decreases as normal cells age, with a half-life of approximately 60 days. Despite very low levels of or no active G6PD, older erythrocytes maintain the ability to produce NADPH and maintain a GSH response to oxidative stress. GdA variant has a half-life of only 13 days, so young cells have a normal amount of enzyme activity whereas older red cells are grossly deficient. Because of this heterogeneity in G6PD levels, individuals with the GdA variant experience only limited hemolysis after oxidant exposure. More than 100 mutations in the G6PD gene, localized to Xq28, have been described. Most mutations are amino acid substitutions that influence enzyme kinetics, stability, or both, with a few rare deletions and splicing mutations described. Because it is X-linked, G6PD deficiency primarily affects males. Males have only one G6PD allele and express only one G6PD type. Females can express one or two G6PD types. The Lyon hypothesis specifies that only one X chromosome is active in any given cell; thus, any given cell in a heterozygous female is either normal or deficient. In females who are heterozygous for G6PD deficiency, average G6PD activity may be normal or mildly, moderately, or severely reduced, depending on the degree of lyonization. G6PD-deficient erythrocytes in heterozygous females are susceptible to the same oxidant stress as G6PD-deficient cells in males, but, typically, the overall degree of hemolysis is less because there is a smaller population of vulnerable cells. Clinical Manifestations G6PD deficiency is divided into five classes based on clinical severity and degree of enzyme deficiency. Class I is characterized by CNSHA without precipitating cause and severe G6PD deficiency. Class II is characterized by intermittent hemolysis and severe G6PD deficiency. Class III is characterized by hemolysis after oxidant stress and mild G6PD deficiency. Classes II and III together represent more than 90% of G6PD variants. Classes IV and V are clinically asymptomatic. The most clinically significant syndromes of G6PD deficiency are acute hemolytic anemia (AHA), neonatal jaundice (NNJ), and rarely, CNSHA. AHA is the most dramatic clinical presentation of G6PD deficiency with acute intravascular hemolysis after exposure to an oxidative stress. Oxidative stresses include ingestion of certain drugs such as primaquine or sulfa-containing compounds, exposure to naphthalene (mothballs), ingestion of fava beans, or infection, the latter being the most common cause of hemolysis. Table 164-2 lists drugs that should be avoided in G6PD-deficient patients. Presenting symptoms include irritability, fever, nausea, abdominal pain, and diarrhea within 48 hours of oxidant exposure. Hemoglobinuria, jaundice, and anemia ensue. The spleen and liver may be enlarged and tender. Cases with severe anemia may precipitate congestive heart failure. Laboratory findings include a normochromic, normocytic anemia with anisocytosis and reticulocytosis. Poikilocytes and bite cells may be seen. Heinz bodies, a classic finding in G6PD deficiency, may be seen but are an inconsistent finding because these damaged cells are rapidly cleared from the

circulation in the spleen. Additional laboratory findings include hemoglobinuria and the presence of free hemoglobin in the blood. Table 164-2 Agents to Be Avoided by Glucose-6-Phosphate DehydrogenaseDeficient Patients Another clinically significant syndrome of G6PD deficiency is NNJ. Jaundice is seldom present at birth, and the peak incidence of onset is between days 2 and 3 of life. The severity of hyperbilirubinemia is variable. It may be severe, resulting in kernicterus or even death. In most cases, however, hyperbilirubinemia is adequately treated with phototherapy. In NNJ, it is important to note that the anemia is very rarely severe. The etiology of NNJ remains controversial. It has been suggested that decreased hepatic elimination of bilirubin is the critical determinant of NNJ. Others suggest that hemolysis is the cause of the jaundice. However, jaundice persists in some cases even when there is no contact with causative agents. NNJ is increased in G6PD-deficient infants who also carry a polymorphism of the uridine diphosphoglucuronyl transferase (UDPGT1) gene associated with Gilbert syndrome. Chronic nonspherocytic hemolytic anemia is associated with uncommon variants of G6PD deficiency, usually mutant enzymes unable to maintain basal NADPH production. Presentation may be in the neonatal period when NNJ is accompanied by anemia in a male. The degree of chronic anemia in CNSHA due to G6PD deficiency has been variable. Some patients have compensated hemolysis, whereas others require intermittent transfusions. Transfusion dependence occurs in the most severe cases. Diagnosis The G6PD reaction (glucose-6-phosphate + NADP+ 6-phosphogluconolactone + NADPH + H+) reduces NADP+ to NADPH. Formation of NADPH and NADH can be observed directly because they fluoresce in the visible spectrum when illuminated with long-wave ultraviolet light. Based on this observation, several simple screening tests performed using inexpensive long-wave ultraviolet light have been devised. These tests are semiquantitative, categorizing a sample as normal or deficient. They are unreliable after an acute hemolytic episode and do not typically detect female heterozygotes. Positive screening tests should be confirmed by spectrophotometric assay or DNA studies. Definitive assay of the enzyme depends on direct spectrophotometric measurement of NADPH production. Although more sensitive than screening tests, this still requires 20 to 30% G6PD-deficient cells to obtain an abnormal result. Sensitivity can be increased by comparing the level of G6PD deficiency to levels of other age-dependent erythrocyte enzymes, especially when testing is temporally in close proximity to an acute hemolytic episode. The cyanide-ascorbate test measures the ability of erythrocytes to prevent the oxidation of hemoglobin by ascorbate. Employing intact erythrocytes, as few as 10 to 15% deficient cells can be detected, making this test useful for detecting female heterozygotes and males following a hemolytic episode. This test also detects other perturbations of the HMP shunt or glutathione metabolism. TREATMENT The best treatment for the individual with AHA is careful prescription of medications and avoidance of inciting agents (see Table 164-2). Outside of acute hemolytic episodes, these patients do not require any special therapy. AHA episodes are managed with particular attention to hematologic, cardiopulmonary, and renal complications of hemolysis. Management of NNJ does not differ from that recommended for other causes of neonatal hyperbilirubinemia. In CNSHA, management is expectant. Exposure to oxidant stresses should be avoided. Blood transfusions may be necessary during acute hemolytic episodes. In severe cases of CNSHA, Hemostasis or haemostasis (from the Ancient Greek: haimstasis "styptic (drug)") is a process which causes bleeding to stop, meaning to keep blood within a damaged blood vessel (the opposite of hemostasis is hemorrhage). It is

the first stage of wound healing. Most of the time this includes blood changing from a liquid to a solid state. All situations that may lead to hemostasis are portrayed by the Virchow's triad. Intact blood vessels are central to moderating blood's tendency to clot. The endothelial cells of intact vessels prevent blood clotting with a heparin-like molecule and thrombomodulin and prevent platelet aggregation with nitric oxide and prostacyclin. When endothelial injury occurs, the endothelial cells stop secretion of coagulation and aggregation inhibitors and instead secrete von Willebrand factor which initiate the maintenance of hemostasis after injury. Hemostasis has three major steps: 1) vasoconstriction, 2) temporary blockage of a break by a platelet plug, and 3) blood coagulation, or formation of a clot that seals the hole until tissues are repaired. Steps of mechanism[edit] Further information: Coagulation

Aggregation of thrombocytes(platelets). Platelet rich human blood plasma (left vial) is a turbid liquid. Upon addition of ADP, platelets are activated and start to aggregate, forming white flakes (right vial) Hemostasis occurs when blood is present outside of the body or blood vessels. It is the instinctive response for the body to stop bleeding and loss of blood. During hemostasis three steps occur in a rapid sequence. Vascular spasm is the first response as the blood vessels constrict to allow less blood to be lost. In the second step, platelet plug formation, platelets stick together to form a temporary seal to cover the break in the vessel wall. The third and last step is called coagulation or blood clotting. Coagulation reinforces the platelet plug with fibrin threads that act as a molecular glue.[1] Platelets are a large factor in the hemostatic process. They allow for the creation of the platelet plug that forms almost directly after a blood vessel has been ruptured. Within seconds of a blood vessels epithelial wall being disrupted platelets begin to adhere to the sub-endothelium surface. It takes approximately sixty seconds until the first fibrin strands begin to intersperse among the wound. After several minutes the platelet plug is completely formed by fibrin.[2] Hemostasis is maintained in the body via three mechanisms: 1. Vascular Spasm - Damaged blood vessels constrict. Vascular spasm is the blood vessels' first response to injury. The damaged vessels will constrict (vasoconstrict) which reduces the amount of blood flow through the area and limits the amount of blood loss. This response is triggered by factors such as a direct injury to vascular smooth muscle, chemicals released by endothelial cells and platelets, and reflexes initiated by local pain receptors. The spasm response becomes more effective as the amount of damage is increased. Vascular spasm is much more effective in smaller blood vessels.[1]

2. Platelet plug formation - Platelets adhere to damaged endothelium to form platelet plug (primary hemostasis) and then degranulate. This process is regulated through thromboregulation. Platelet Plug Formation: Platelets play one of the biggest factors in the hemostatic process. Being the second step in the sequence they stick together (aggregation) to form a plug that temporarily seals the break in the vessel wall. As platelets adhere to the collagen fibers of a wound they become spiked and much stickier. They then release chemical messengers such as adenosine diphosphate (ADP), serotonin and thromboxane A2. These chemicals are released to cause more platelets to stick to the area and release their contents and enhance vascular spasms. As more chemicals are released more platelets stick and release their chemicals; creating a platelet plug and continuing the process in a positive feedback loop. Platelets alone are responsible for stopping the bleeding of unnoticed wear and tear of our skin on a daily basis.[3] The second stage of Hemostasis involves platelets that move throughout the blood. When the platelets find an exposed area or an injury, they begin to form what is called a platelet plug. The platelet plug formation is activated by a glycoprotein called the Von Willebrand factor (vWF), which are found in the bodys blood plasma. When the platelets in the blood are activated, they then become very sticky so allowing them to stick to other platelets and adhere to the injured area.[4][5] There are a dozen proteins that travel along the blood plasma in an inactive state and are known as clotting factors. Once the platelet plug has been formed by the platelets, theclotting factors begin creating the platelet plug. When this occurs the clotting factors begin to form a collagen fiber called fibrin. Fibrin mesh is then produced all around the platelet plug, which helps hold the fibrin in place. Once this begins, red and white blood cells become caught up in the fibrin mesh which causes the clot to become even stronger.[3] 3. Blood coagulation - Clots form upon the conversion of fibrinogen to fibrin, and its addition to the platelet plug (secondary hemostasis). Coagulation: The third and final step in this rapid response reinforces the platelet plug. Coagulation or blood clotting uses fibrin threads that act as a glue for the sticky platelets. As the fibrin mesh begins to form the blood is also transformed from a liquid to a gel like substance through involvement of clotting factors and procoagulants. The coagulation process is useful in closing up and maintaining the platelet plug on larger wounds. The release of Prothrombin also plays an essential part in the coagulation process because it allows for the formation of a thrombus, or clot, to form. This final step forces blood cells and platelets to stay trapped in the wounded area. Though this is often a good step for wound healing, it has the ability to cause severe health problems if the thrombus becomes detached from the vessel wall and travels through the circulatory system; If it reaches the heart or brain it could lead tostroke, heart attack, or pulmonary embolism. However, without this process the healing of a wound would not be possible.[1] Types of Hemostasis Hemostasis can be achieved in various other ways if the body cannot do it naturally (or needs help) during surgery or medical treatment. When the body is under shock and stress, hemostasis is harder to achieve. Though natural hemostasis is most desired, having other means of achieving this is vital for survival in many emergency settings. Without the ability to stimulate Hemostasis the risk of hemorrhaging is great. During surgical procedures the types of hemostasis listed below can be used to control bleeding while avoiding and reducing the risk of tissue destruction. Hemostasis can be achieved by chemical agent as well as mechanical or physical agents. Which hemostasis type used is determined based on the situation.[6] Hemostasis in emergency medicine

Debates still continue to rise on the subject of hemostasis and how to handle situations with large injuries. If an individual did acquire a large injury resulting in extreme blood loss, then a hemostatic agent alone would not be very effective. Medical professionals continue to debate on what the best ways to assist a patient in a chronic

state are; however, it is universally accepted that hemostatic agents are the primary tool for smaller bleeding injuries.[6] Some main types of hemostasis used in emergency medicine include:

Chemical/topical- This is a topical agent often used in surgery settings to stop bleeding. Microfibriller collagen is the most popular choice among surgeons because it attracts the patients natural platelets and starts the blood clotting process when it comes in contact with the platelets. This topical agent requires normal hemostatic pathway to be properly functional.[7] Direct pressure or pressure dressing- This type of hemostasis approach is most commonly used in situations where proper medical attention is not available. Putting pressure and/or dressing to a bleeding wound only slows the process of blood loss, allowing for more time to get to an emergency medical setting. Soldiers use this skill during combat when someone has been injured because this process allows for blood loss to be decreased, giving the system time to start coagulation.[8] Sutures and ties- Sutures are often used to close an open wound, allowing for the injured area to stay free of pathogens and other unwanted debris to enter the site; however, it is also essential to the process of hemostasis. Sutures and ties allow for skin to be joined back together allowing for platelets to start the process of hemostasis at a quicker pace. Using sutures results in a quicker recovery period because the surface area of the wound has been decreased.[9] Physical agents ( gelatin sponge )- Gelatin sponges have been indicated as great hemostatic devices. Once applied to a bleeding area, a gelatin sponge quickly stops or reduces the amount of bleeding present. These physical agents are mostly used in surgical settings as well as after surgery treatments. These sponges absorb blood, allow for coagulation to occur faster, and give off chemical responses that decrease the time it takes for the hemostasis pathway to start.[10]

Disorders[edit] The body's hemostasis system requires careful regulation in order to work properly; if the blood does not clot sufficiently, bleeding disorders such as hemophilia can result. Over-active clotting can also cause problems; thrombosis, where blood clots form abnormally, can potentially cause embolisms, where blood clots break off and subsequently become lodged in a vein or artery. Hemostasis disorders can develop for many different reasons. They may be congenital, due to a deficiency or defect in an individual's platelets or clotting factors. A number of disorders can be acquired as well, such as in HELLP syndrome, which is due to pregnancy, or Hemolytic-uremic syndrome (HUS), which is due to E. coli toxins. History of Artificial Hemostasis[ The process of preventing blood loss from a vessel or organ of the body is referred to as hemostasis. The term comes from the Ancient Greek roots "heme" meaning blood, and "stasis" meaning halting; Put together means the "halting of the blood".[1] The origin of hemostasis dates back as far as ancient Greece; first referenced to being used in the Battle of Troy. It started with the realization that excessive bleeding inevitably equaled death. Vegetable and mineral styptics were used on large wounds by the Greeks and Romans until the takeover of Egypt around 332BC by Greece. At this time many more advances in the general medical field were developed based off the study of Egyptian mummificationpractice, which led to greater knowledge of the hemostatic process. It was during this time that many of the veins and arteries running throughout the human body were found and the directions in which they traveled. Doctors of this time realized if these were plugged, blood could not continue to flow out of the body.

Nevertheless it took until the invention of the printing press during the fifteenth century for medical notes and ideas to travel westward, allowing for the idea and practice of Hemostasis to be expanded.[11] Hemostatic Research There is currently a lot of research being conducted on hemostasis. The most current research is based on genetic factors of hemostasis and how it can be altered to reduce the cause of genetic disorders that alter the natural process hemostasis.[12] Von Willebrand disease is associated with a defect in the ability of the body to create the platelet plug and the fibrin mesh that ultimately stops the bleeding. New research is concluding that the von Willebrand disease is much more common in adolescence. This disease negatively hinders the natural process of Hemostasis causing excessive bleeding to be a concern in patients with this disease. There are complex treatments that can be done including a combination of therapies, estrogen-progesterone preparations,desmopressin, and Von Willebrand factor concentrates. Current research is trying to find better ways to deal with this disease; however, much more research is needed in order to find out the effectiveness of the current treatments and if there are more operative ways to treat this disease hrombosis (Greek: ) is the formation of a blood clot (thrombus; Greek: ) inside a blood vessel, obstructing the flow of blood through the circulatory system. When a blood vessel is injured, the body uses platelets (thrombocytes) and fibrin to form a blood clot to prevent blood loss. Even when a blood vessel is not injured, blood clots may form in the body under certain conditions. A clot that breaks free and begins to travel around the body is known as an embolus.[1][2] When a thrombus is significantly large enough to reduce the blood flow to a tissue, hypoxia (oxygen deprivation) can occur and metabolic products such as lactic acid can accumulate. A larger thrombus causing a much greater obstruction to the blood flow may result in anoxia, the complete deprivation of oxygen and infarction, tissue death. There are also a number of other conditions that can arise according to the location of the thrombus and the organs affected. Thromboembolism is the combination of thrombosis and its main complication, embolism. Contents [hide]

1 Causes
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1.1 Hypercoagulability 1.2 Endothelial cell injury 1.3 Disturbed blood flow

2 Classification
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2.1 Venous thrombosis 2.2 Arterial thrombosis

3 Embolization 4 Prevention 5 Treatment

6 See also 7 References 8 External links

Causes[edit] In classical terms, thrombosis is caused by abnormalities in one or more of the following (Virchow's triad):

The composition of the blood (hypercoagulability or thrombophilia) Quality of the vessel wall (endothelial cell injury) Nature of the blood flow (stasis, turbulence)

Hypercoagulability[edit] Main article: Thrombophilia Hypercoagulability is caused by, for example, genetic deficiencies or autoimmune disorders. Recent studies indicate that neutrophils play a pivotal role in deep vein thrombosis, mediating numerous pro-thrombotic actions[3][4][5] Endothelial cell injury[edit] Causes of injury to the vessel's wall include trauma, surgery, infection or turbulent flow at bifurcations. The main mechanism is exposure of tissue factor to the blood coagulation system.[6] Disturbed blood flow[edit] Further information: Blood flow Causes of disturbed blood flow include stagnation of blood flow past the point of injury, or venous stasis which may occur in heart failure,[6] in or after long periods of sedentary behavior, such as sitting on a long airplane flight. Also, atrial fibrillation, causes stagnant blood in the left atrium (LA) or left atrial appendage (LAA), and can lead to a thromboembolism.[6] Cancers or malignancies such as leukemia may cause increased risk of thrombosis by possible activation of the coagulation system by cancer cells or secretion of procoagulant substances (paraneoplastic syndrome), by external compression on a blood vessel when a solid tumor is present, or (more rarely) extension into the vasculature (for example, renal cell cancers extending into the renal veins).[6] Also, treatments for cancer (radiation, chemotherapy) often cause additional hypercoagulability.[6] Classification[edit] There are two distinct forms of thrombosis, venous thrombosis and arterial thrombosis, each of which can be presented by several subtypes. Venous thrombosis[edit] Main article: Venous thrombosis Venous thrombosis is the formation of a thrombus (blood clot) within a vein. There are several diseases which can be classified under this category: Deep vein thrombosis[edit]

Main article: Deep vein thrombosis Deep vein thrombosis (DVT) is the formation of a blood clot within a deep vein. It most commonly affects leg veins, such as the femoral vein. Three factors are important in the formation of a blood clot within a deep veinthese are the rate of blood flow, the thickness of the blood and qualities of the vessel wall. Classical signs of DVT include swelling, pain and redness of the affected area. Portal vein thrombosis[edit] Main article: Portal vein thrombosis Portal vein thrombosis affects the hepatic portal vein, which can lead to portal hypertension and reduction of the blood supply to the liver.[7] It usually has a pathological cause such as pancreatitis, cirrhosis, diverticulitis or cholangiocarcinoma. Renal vein thrombosis[edit] Main article: Renal vein thrombosis Renal vein thrombosis is the obstruction of the renal vein by a thrombus. This tends to lead to reduced drainage from the kidney. Anticoagulation therapy is the treatment of choice. Jugular vein thrombosis[edit] Main article: Jugular vein thrombosis Jugular vein thrombosis is a condition that may occur due to infection, intravenous drug use or malignancy. Jugular vein thrombosis can have a varying list of complications, including: systemic sepsis, pulmonary embolism, and papilledema. Though characterized by a sharp pain at the site of the vein, it can prove difficult to diagnose, because it can occur at random.[8] Budd-Chiari syndrome[edit] Main article: Budd-Chiari syndrome Budd-Chiari syndrome is the blockage of the hepatic vein or the inferior vena cava. This form of thrombosis presents with abdominal pain, ascites and hepatomegaly. Treatment varies between therapy and surgical intervention by the use of shunts. Paget-Schroetter disease[edit] Main article: Paget-Schroetter disease Paget-Schroetter disease is the obstruction of an upper extremity vein (such as the axillary vein or subclavian vein) by a thrombus. The condition usually comes to light after vigorous exercise and usually presents in younger, otherwise healthy people. Men are affected more than women. Cerebral venous sinus thrombosis[edit] Main article: Cerebral venous sinus thrombosis Cerebral venous sinus thrombosis (CVST) is a rare form of stroke which results from the blockage of the dural venous sinuses by a thrombus. Symptoms may include headache, abnormal vision, any of the symptoms of stroke such as

weakness of the face and limbs on one side of the body and seizures. The diagnosis is usually made with a CT or MRI scan. The majority of persons affected make a full recovery. The mortality rate is 4.3%.[9] Arterial thrombosis[edit] Arterial thrombosis is the formation of a thrombus within an artery. In most cases, arterial thrombosis follows rupture of atheroma, and is therefore referred to as atherothrombosis. Another common cause of arterial occlusion is atrial fibrillation, which causes a blood stasis within the atria with easy thrombus formation. In addition, it is well known that the direct current cardioversion of atrial fibrillation carries a great risk of thromboembolism, especially if persisting more than 48 hours. Thromboembolism strikes approximately 5% of cases not receiving anticoagulant therapy. When cardiac rhythm is restored clots are pushed out from atria to ventricles and from these to the aorta and its branches.[10] Arterial thrombosis can embolize and is a major cause of arterial embolism, potentially causing infarction of almost any organ in the body. Stroke[edit] Main article: Stroke A stroke is the rapid decline of brain function due to a disturbance in the supply of blood to the brain. This can be due to ischemia, thrombus, embolus (a lodged particle) orhemorrhage (a bleed). In thrombotic stroke, a thrombus (blood clot) usually forms around atherosclerotic plaques. Since blockage of the artery is gradual, onset of symptomatic thrombotic strokes is slower. Thrombotic stroke can be divided into two categorieslarge vessel disease and small vessel disease. The former affects vessels such as the internal carotids, vertebral and the circle of Willis. The latter can affect smaller vessels such as the branches of the circle of Willis. Myocardial infarction[edit] Main article: Myocardial infarction Myocardial infarction (MI) or heart attack, is caused by ischemia, (restriction in the blood supply), often due to the obstruction of a coronary artery by a thrombus. This restriction gives an insufficient supply of oxygen to the heart muscle which then results in tissue death,(infarction). A lesion is then formed which is the infarct. MI can quickly become fatal if emergency medical treatment is not received promptly. If diagnosed within 12 hours of the initial episode (attack) then thrombolytic therapy is initiated. Other sites Hepatic artery thrombosis usually occurs as a devastating complication after liver transplantation.[11] An arterial embolus can also form in the limbs.[12] Embolization If a bacterial infection is present at the site of thrombosis, the thrombus may break down, spreading particles of infected material throughout the circulatory system (pyemia, septic embolus) and setting up metastatic abscesses wherever they come to rest. Without an infection, the thrombus may become detached and enter circulation as an embolus, finally lodging in and completely obstructing a blood vessel, which unless treated very quickly will lead to tissue necrosis (an infarction) in the area past the occlusion. If the occlusion is in the coronary artery, myocardial ischaemia is likely to

occur, whereby cardiac myocytes cannot function properly due to lack of oxygen. This lack of oxygen is then likely to result in a myocardial infarction. Most thrombi, however, become organized into fibrous tissue, and the thrombosed vessel is gradually recanalized. Prevention Prophylaxis of venous thromboembolism with heparin in medical patients does not appear to decrease mortality and while it may decrease the risk of pulmonary embolism anddeep vein thrombosis it increases the risk of bleeding and thus results in little or no overall clinical benefit.[13][14] Mechanical measures also appeared of little benefit in this group and in those with a stroke resulted in harm.[13] Evidence supports the use of heparin following surgery which has a high risk of thrombosis to reduce the risk of DVTs; however the effect on PEs or overall mortality is not known.[15][16][17] Generally, a risk-benefit analysis is required, as all anticoagulants lead to a small increase in the risk of major bleeding. In atrial fibrillation, for instance, the risk of stroke(calculated on the basis of additional risk factors, such as advanced age and high blood pressure) needs to outweigh the small but known risk of major bleeding associated with the use of warfarin.[18] In people admitted to hospital, thrombosis is a major cause for complications and occasionally death. In the UK, for instance, the Parliamentary Health Select Committee heard in 2005 that the annual rate of death due to thrombosis was 25,000, with at least 50% of these being hospital-acquired.[19] Hence thromboprophylaxis (prevention of thrombosis) is increasingly emphasized. In patients admitted for surgery, graded compression stockings are widely used, and in severe illness, prolonged immobility and in all orthopedic surgery,professional guidelines recommend low molecular weight heparin (LMWH) administration, mechanical calf compression or (if all else is contraindicated and the patient has recently suffered deep vein thrombosis) the insertion of a vena cava filter.[20][21] In patients with medical rather than surgical illness, LMWH too is known to prevent thrombosis,[21][22] and in the United Kingdom the Chief Medical Officer has issued guidance to the effect that preventative measures should be used in medical patients, in anticipation of formal guidelines.[19] Treatment Coumarins, Vitamin K antagonists, are anticoagulants that can be taken orally to reduce thromboembolic occurrence. Where a more effective response is required, heparin can be given (by injection) concomitantly. As a side effect of any anticoagulant, the risk of bleeding is increased, so the international normalized ratio of blood is monitored. Selfmonitoring and self-management are safe options for competent patients, though their practice varies. In Germany, about 20% of patients were self-managed while only 1% of U.S. patients did home self-testing (according to one 2012 study