Clots and bleeding

What do clots and bleeding mean?

Blood clotting is a normal job of the body, and when a vessel is injured it stops the bleeding. Sometimes a clot forms in a vessel without an injury, or does not dissolve by itself. Sometimes it is the other way round: blood does not clot well and bleeding goes on for a long time.

Clots. A clot in a vein can block blood from returning to the heart and cause pain and swelling. A clot in a deep vein of the leg is called DVT. If a clot breaks loose and reaches the lung, it is called a pulmonary embolism, which is serious and needs urgent treatment. A clot in an artery can also lead to a heart attack or stroke.

Things that raise the risk of a vein clot: cancer, major surgery or injury, long periods without moving (including long trips), pregnancy, smoking, hormonal birth control pills, obesity, age over 60, family history, diabetes, high blood pressure and high cholesterol, and having a venous catheter. Still, not everyone with these factors gets a clot, and sometimes a clot happens with no clear cause.

Bleeding. Bleeding disorders occur when platelets are low or do not work well, or when the clotting proteins are low or faulty. Hemophilia and von Willebrand disease are the best-known inherited types. Platelet disorders are the most common cause and are mostly acquired, not inherited.

What are the symptoms?

• Clot in the leg: throbbing pain in one leg (usually the calf or thigh), swelling of one leg, warmth and tenderness, and redness or bruising of the skin, which is harder to see on darker skin.
• Pulmonary embolism: sudden shortness of breath, chest pain that gets worse with breathing, coughing up blood, a fast heartbeat, sweating. This is an emergency.
• Bleeding disorder: easy bruising, bleeding gums, nosebleeds without a reason, heavy periods, bleeding that goes on after a small cut or dental work, and long bleeding after surgery. Bleeding into a joint is seen in hemophilia.

How is it diagnosed?

• Clot: the doctor usually refers based on symptoms and history, and for a leg clot an ultrasound is done (to see the blood flow in the vessel). If the cause of the clot is not clear, more tests or investigations may be needed.
• Bleeding: a platelet count is one of the first checks, and from the result, the symptoms and the family history the doctor decides what other test is needed. A low or high platelet count has many causes and is only a sign, not a diagnosis.

How is it treated?

• Clot: almost all patients receive an anticoagulant medicine (known as a “blood thinner”) so that the clot does not grow and does not form new clots. These medicines do not actually thin the blood; they slow down the clotting process. They are usually taken for at least a few months, but the doctor sets the exact period depending on the cause of the clot. In special cases, other methods such as clot-dissolving medicines or removing the clot are used.
• Bleeding: treatment depends on the type of disease. People with mild von Willebrand disease may need no treatment but should avoid aspirin and ibuprofen. In hemophilia, replacement clotting factors are used. If platelets are low, the doctor finds the cause and treatment follows from that.

Follow-up and care at home

If you take an anticoagulant:

• Never stop it or change the amount without the doctor’s advice. If it has to be paused before surgery or a test, the doctor arranges it.
• Tell every doctor and dentist that you take this medicine, and if you have a medicine alert card, always carry it.
• Before starting any medicine, painkiller or supplement, even without a prescription, ask your doctor or pharmacist. Some painkillers (such as ibuprofen and aspirin) and herbal products interact with these medicines.
• Watch for signs of bleeding: blood in the urine or stool, black stools, severe or widespread bruising, long nosebleeds or gum bleeding, vomiting or coughing blood.
• After clot treatment starts, discuss air travel or long trips with the doctor. It is better to take flights and long journeys at least two weeks after starting the medicine.
• To prevent a leg clot on a long trip, move every so often and wear loose clothing.

If you have low platelets (for example during chemotherapy): a very soft toothbrush, shoes at home, an electric shaver instead of a blade, and avoiding painkillers that contain aspirin or ibuprofen unless the doctor allows them. For bleeding, press firmly on the spot with a clean cloth.

When to call

Emergency (115, Iran’s emergency number) or go right away:

• Sudden shortness of breath, chest or back pain, a very fast heartbeat, or fainting. In this situation do not drive yourself.
• Pain and swelling in one leg together with shortness of breath or chest pain.
• Severe bleeding that will not stop, vomiting or coughing blood.
• A blow to the head, or a sudden severe headache with confusion, trouble speaking or weakness of the arm or leg, in someone who takes an anticoagulant.

See a doctor at the first opportunity:

• Pain, swelling and warmth in one leg.
• A nosebleed or gum bleeding that lasts, bruising without a reason, or tiny red or purple spots on the skin.
• Periods much heavier than usual.

Every patient’s treatment plan is different; ask your doctor about your own situation.