Symptoms of Internal Bleeding

Internal bleeding occurs when you bleed, and the blood collects inside the body instead of bleeding out through an open wound. Symptoms of internal bleeding, known as hemorrhaging, can vary from one case to the next.

Internal bleeding can be sudden and rapid, with extreme pain, shock, and fainting. Or, it can be slow and "silent" with few symptoms until the loss of blood is extreme. However, the symptoms don't always reflect the amount of bleeding and its severity.

This article examines the causes, symptoms, and complications of internal bleeding and the signs that indicate the need for emergency care.

Causes

The causes of internal bleeding are as varied as the signs and symptoms. Some are caused by an external force, such as a blow to the body, while others occur within the body due to a disease or structural weakness.

Trauma

Trauma is one of the more common causes of internal bleeding. It can include various types of injuries:

• Penetrating trauma: This is when an object enters the body, such as a knife, broken glass, shrapnel, or a bullet.
• Blunt trauma: This can range from knocks and punches, which may not cause noticeable symptoms at first, to high-velocity impacts, which often do.
• Deceleration injuries: These commonly occur in car crashes. When a speeding vehicle abruptly stops, it can cause vessels and organs to rupture or detach.
• Fractures: Some fractures bleed more than others. Fractures of the long arm, leg, and pelvis bones can cause significant blood loss. Bone fragments can also tear blood vessels.

Aneurysm

An aneurysm is a bulge in a blood vessel caused by a weakness in the wall. This can cause the vessel to rupture. Sometimes, the rupture of an aneurysm happens with intense activity. At other times, it can occur for no apparent reason during rest or sleep.

Aneurysms can occur in any blood vessel, although they are more common in the brain (cerebral aneurysm) or the aorta, either in the chest (ascending or descending thoracic aortic aneurysm) or abdomen (abdominal aortic aneurysm).

Bleeding Disorders

Bleeding disorders such as hemophilia can increase a person's risk of bleeding, including internal bleeding. This is caused when blood does not clot as it should, either due to a lack of blood cells called platelets or proteins called clotting factors.

The overuse of certain drugs can have the same effect. This includes blood thinners like warfarin and anti-platelet drugs like Plavix (clopidogrel). Even nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and Advil (ibuprofen) can cause internal bleeding if used in excess, especially if you have a peptic ulcer or any other condition that causes gastric (stomach) bleeding.

Hemorrhagic Fevers

A less common cause of internal bleeding is viral hemorrhagic fevers. Certain viruses can cause small blood clots in blood vessels throughout the body. By doing so, there are fewer platelets available to stop bleeding.

Common symptoms include vomiting, diarrhea, muscle pain, tiny red or purple spots on the skin (called petechiae), bleeding, and a drop in blood pressure.

Many viral diseases can cause internal bleeding, most of which are confined to Africa. These include:

• Chikungunya fever
• Dengue fever
• Ebola virus
• Hantavirus
• Lassa fever
• Rift valley fever
• Yellow fever

Signs and Symptoms

The symptoms of internal bleeding do not always correspond to the severity of the bleeding.

For example, large amounts of blood may be lost following an abdominal or kidney injury before symptoms appear. By contrast, even small amounts of bleeding in parts of the brain can cause significant symptoms and even death.

In trauma cases, the initial lack of signs or symptoms does not mean that a person is in the clear. It is only later that symptoms may develop and turn severe.

Symptoms of internal bleeding include:

Lightheadedness

Lightheadedness and dizziness are common with rapid or massive blood loss. In cases where the blood loss is gradual, lightheadedness may only occur when a person tries to stand and the blood pressure drops (orthostatic hypotension).

Pain

Pain is a common symptom of internal bleeding, as blood irritates tissues. The pain may be confined to the bleeding area in some parts of the body, such as the chest. With others, like the abdomen, the pain may be felt in other parts of the body (known as referred pain). For instance, bleeding near the diaphragm is often felt in the shoulder.

Guarding

It is common for people to display guarding when internal bleeding occurs. Guarding is an unconscious attempt to keep a person from touching a part of the body that is tender or injured.

Shortness of Breath

Shortness of breath can be a symptom of internal bleeding in any body part. With blood loss, fewer red blood cells carry oxygen to tissues, which causes trouble breathing.

Tingling in Hands and Feet

With blood loss, the body often "clamps down" on vessels in the limbs to re-direct blood to essential organs. Losing oxygen to the limbs can cause tingling in the hands or feet. Internal bleeding can also cause hyperventilation (rapid breathing) as the body tries to raise oxygen levels.

Changes in Vision

Vision changes are common with internal bleeding. They can occur before "blacking out" when the blood loss is rapid or severe. Other changes may be due to a brain bleed, in which blurred and double vision are common.

Nausea or Vomiting

Nausea and vomiting may occur due to blood loss or in response to pain. These symptoms are expected when the bleeding is in the digestive tract or the brain.

Profuse Sweating

Heavy sweating for no apparent reason (called diaphoresis) can occur when blood loss is sudden or severe. The loss of blood can cause a rapid change in body temperature, which can cause sudden, extreme sweating. People often describe this as "breaking out in a cold sweat."

Bruising

Bruising can sometimes indicate where a bleed is occurring. Bruising around the navel, referred to as a Cullen's sign, suggests bleeding in the belly. Bruising on the flank, known as Grey Turner's sign, can occur when bleeding in the abdomen or retroperitoneal space (where the kidneys are located). Extensive bruising can occur with fractures.

Change in Mental Status

A change in mental status, including confusion and disorientation, is a sign that a lot of blood has been lost. This can include a total loss of consciousness. A change in mental status is a sign of a medical emergency.

Site-Specific Symptoms

Internal bleeding in specific parts of the body may lead to distinct symptoms. These include:

Brain

Brain bleeds often cause severe headaches, nausea, and vomiting. Weakness on one side of the body or changes in vision are also common. As the bleeding progresses, confusion and disorientation can occur, followed by the loss of consciousness or seizures.

Chest

Bleeding in the chest can cause shortness of breath, a gasping cough, and hemoptysis (coughing up blood). Coughing up even just a teaspoon of blood is a medical emergency. Coughing up to 1/4 cup of blood or more is linked to a high risk of death.

Bleeding around the heart (known as pericardial effusion) can restrict the heart's motion. This can lead to life-threatening cardiac tamponade.

When a lung is punctured and collapses (pneumothorax), bruising is often seen around the chest and neck. The skin of the neck and upper belly may also feel crinkly, like bubble wrap, as air enters the layers of skin. The pain can increase with blood in the chest (hemothorax) when people move into different positions.

Abdomen

Bleeding into the abdomen can cause swelling along with diffuse pain. When a doctor places a stethoscope on the stomach, bowel sounds may be absent. Bruising around the navel or flank strongly suggests internal bleeding.

Bleeding into the esophagus or stomach can lead to bloody vomit, while bleeding in the lower digestive tract may cause rectal bleeding or bloody stools. Bleeding in the kidneys or bladder can cause blood in the urine.

Bones, Joints, and Muscles

Bleeding due to fractures or joint or muscle injuries usually causes bruising, sometimes severe. On the other hand, the skin may turn pale and tight when bleeding causes compartment syndrome. This is a painful condition caused by extreme pressure within muscle tissues. It may be hard to move joints or walk.

Diagnosis

Internal bleeding is diagnosed with lab tests and imaging tools.

Lab Tests

There are a few different ab tests that can detect internal bleeding. A blood test can show if someone has anemia (low red blood cells) due to blood loss. A stool sample can be tested for occult blood (blood in the stool). Lab tests can also test for bleeding disorders and other illnesses.

Imaging Tests

In cases of severe trauma, such as a bad car accident, healthcare professionals might do a CT scan of the person from head to toe, known as a pan-scan, to look for injuries and bleeding.

However, imaging will usually be localized to the region that experienced injury or shows signs of bleeding. Imaging tests, such as X-rays, CT scans, ultrasounds, angiograms, and endoscopy, can help pinpoint the location of the bleeding.

Complications

The loss of blood can lead to severe complications. This can include death caused by the massive loss of blood, known as exsanguination. This most often occurs when half to two-thirds of the body's blood is lost.

But other complications can lead to death or permanent injury:

Shock

Shock is a medical emergency when the tissues in your body can't get enough blood and oxygen. When it is due to a low volume of blood, such as caused by bleeding, it is referred to as hypovolemic shock.

Most often, the signs of shock (including clammy skin, rapid heartbeat, and difficulty breathing) occur when a person has lost between 10% and 15% of their blood volume.

Organ Failure or Damage

Some organs are more sensitive to blood loss and shock than others. In the heart and kidneys, for instance, the lack of blood flow causes tissues to die quickly, a process called necrosis. This can reduce the function of these organs, often permanently, leading to organ failure.

The same can occur with brain bleeds, in which tissue death can lead to paralysis, vision loss, personality changes, memory loss, and problems swallowing.

Special Populations

Bleeding can raise particular concerns in different groups of people, most specifically children and pregnant people.

Children

Unlike adults, children may not be able to describe their symptoms. Instead of complaining of pain, they may become fussy, cry continually, or become difficult to console. They may also have a poor appetite or refuse to eat.

Changes in mental status are also common clues. For instance, a child who normally loves to play may become lethargic. Vision changes can cause a child to bump into walls or miss objects they are reaching for.

Pregnancy

Early on in pregnancy, bleeding may be the sign of a miscarriage or a more potentially deadly condition called an ectopic pregnancy. Later on, placenta previa, placental abruptions, or uterine rupture can cause internal bleeding.

Complications like these often cause vaginal bleeding, but this is not always the case. The position of the baby in the womb may prevent blood from escaping. This can increase the risk of a late diagnosis and death.

When to See a Doctor

Internal bleeding can be life-threatening and requires immediate action to prevent death or irreversible organ damage.

It is essential to call 911 if you or someone you know shows signs of internal bleeding, including:

• Severe abdominal or chest pain
• Shortness of breath or trouble breathing
• Lightheadedness or fainting
• Coughing up blood
• Changes in vision
• Changes in mental status

People should also be examined after any sort of trauma, including severe falls or blunt force injuries caused by car accidents or contact sports. These sometimes do not cause outward symptoms until later when the blood loss is severe.

Summary

Internal bleeding is commonly caused by things like trauma (including puncture wounds, fractures, and blunt force injuries) as well as ruptured aneurysms and bleeding disorders. The overuse of certain drugs and viral hemorrhagic fevers are uncommon but potentially serious causes.

Symptoms include pain, lightheadedness, nausea or vomiting, bruising, cold sweat, tingling hands or feet, vision changes, confusion, and fainting. Complications may include shock, organ damage or failure, and death.