SCENARIO

A girl aged 5 years old, was

brought to the hospital because
she got red spots on her arm,
lower extremities and abdomen,
blood coming out from her anus
with no fever. 6 days ago, she had
just recovered from cough with
rhinorrhea.

KEYWORDS
girl aged 5 years old
red spots on her arm, lower extremities
and abdomen
blood coming out from her anus
no fever
Previous cough and rhinorrhea, 6 days
ago.

TERMS CLARIFICATION
Hemorrhage:the escape blood from the vessel.
Petechia : a red spot due to escape of a small of blood.
Purpura
: a small hemorrage in the skin,mucous
membrane, or
serous surface.
Ecchymoses:a small hemorrhagic spot in the skin or a
mucous
membrane, larger than a petechia,
forming a
nonelevated, rounded, or irregular
blue or purplish
patch.
Melena
: the passage of dark stools stained with
altered blood by
the intestinal juices.
Hematochezia : the passage of red bloody stools

QUESTIONS
How is the mechanism of
hemostasis?
How hemmorhage or bleeding can
occur?
What is the correlation of previous
disease with the symptom?
Differential diagnosis and their
description.

HEMOSTASIS

BLOOD COAGULATION

FIBRINOLYSIS 1

FIBRINOLISIS 2
INTRINSIK
XIIa
KALIKREIN

EKSTRINSIK

EKSOGEN

t-PA
UROKINASE
AKTIVATOR
PLASMINOGEN

PLASMINOGEN
TERIKAT
PLASMINOGEN
BEBAS

PLASMIN
TERIKAT

FIBRIN
FDP

PLASMIN
BEBAS

FIBRINNOGEN
FV
F VIII

ANTI PLASMIN

HEMORRHAGE?
Vascular abnormality
Thrombocyte abnormality
Coagulation abnormality
Deficiency vitamin K
Trauma

DIFFERENTIAL
DIAGNOSIS

Disseminated Intravasucular
Coagulation
Idiophatic Thrombocytopenic
Purpura
Henoch Schoenlein Syndrome
von Willebrand Disease
Hemophilia A

TABLE
DIC ITP

HENOCH
SCHOENLI
EN
SYNDROME

VONEWILL HEMOPHILIA
EBRAND
A
SYNDROME

PETECHIA

+
(PURPURA)

HEMATOCHEZ
IA

+/-

+/-

+/-

+/-

NO FEVER
PREVIOUS
COUGH &
RHINORRHEA
CHILDREN 5
Y.O

DISSEMINATED
INTRAVASCULAR
COAGULATION

Definition
Disseminated intravascular coagulation (DIC) is a
complex systemic thrombohemorrhagic disorder
involving the generation of intravascular fibrin
and the consumption of procoagulants and
platelets.
DIC is a syndrome arising as a complication of
many different serious and life-threatening
illnesses.

CONT
Synonim: Consumption coagulopathy ,
Hiperfibrinolytic activation,
defibrination and
thrombohemorragic disorder

ET IOLOGY

Obstretical complication:
- abruptio placentae
- amniotic fluid embolism
- dead fetus syndrome
- Septic abortion

Trauma : - burns
Infection: - bacteria
Sepsis
- viral
viremia
Immunologic = Blood transfusion mistake
Malignancy, example : Leukemia

PATOMECANIS
M
Precipitating Mechanism

Tissue damage
damage
Tissue tromboplastin
intrinsic
(F III)
coagulation
Extrinsic pathway of
plasma
Coagulation

Endothelial

Stimulate
pathway of
(F. XII from blood
protein)

Disseminated
Coagulation process
Occlusion
Consumption
blood vessel
factor

Intravascular trombin- fibrin >>

- Coagulation
- platelet.

Tissue ischemic
/organs +++
Reduce:
FDP
- platelet
Necrosis

Fibrinolysis >>(Homeostasis)

- Coagulation factor

coagulation inhibited
Bleeding

CLINICAL
SYMPTOMS

DIC => Trombosis and bleeding can be happen together

1. Hemorrhagic diatesis : Bleeding preference.
- Dermatology : Petechiae, ecchymosis of skin or
mucous membrane
finger ganggrenous.
- Gastro : Hematemesis, hematochezia, and visceral
hemorrhage
- Genitourinary : Hematuria, metrorrhagia.
- Ginggival bleeding.
2. Dispneu
3. tachycardia, tachypnea, and hypotension
5. In severe cases, patients may develop fever

LABORATORY FINDING
Blood shows an abnormalities coagulation because of fibrinogen
deficiency.
Hemostatic Examination :
1. Platelet count decreased
2. Decreased fibrinogen level
3. Prolonged prothrombin time, activated partial
thromboplastin time, thrombin time
4. Increased levels of FDP ( on testing for FDP, D-dimer)
5. Schistocytes on peripheral smear

TREATMENT
1. Individual treatment
- Treatment closely with the etiology, ages, and hemodinamic situation.
- Determine the underlying cause of the patient's DIC and initiate
therapy
2. General:
a. Monitor vital signs and attend to life-threatening issues such as airway
compromise

b. Stop the coagulation :

Exp: Heparin, give if :
- Primary disease cant be stop quickly
- With ischemia or thromboembolism
c. Substitution treatment
transfusions of fresh frozen plasma or platelet.
d. Asam traneksamat as antifibrinolysis if indicated

Henoch Schoelein
Syndrome

Henoch Scholein
Syndrome

An abnormal inflamation process

that involve a peripheral vaskuler
wall especially at skin, digestivus
track, kidney and joints.
Insidens :

Children, 2 8 years old

Male : Female = 2 : 1
More incidence happen at the spring
and winter

Etiology
Idiopatik
Immune reaction
IgA
Infection
Virus or bakteria
Herediter
Drugs allergy
Insect bitting
Food

Clinical Manifestation
Rash
Purpura (ex : Petechiae )
Abdominal pain
Poliatralgia + Joint swelling
Gastrointestinal bleeding
Renal / Kidney Disease
CNS manifestation

Patomechanism
Etiology of HSS
Increased production of IgA
IgA spreading out and gathered at the
peripehral vaskuler wall
Disturbing and Altering the vaskular
endotel cell main function

Patomechanism
Endotel cell stimulates chemical mediator,
such as TNF alfa and IL 8
Increased of an abnormal apoptosis of
endotelial cell
Neutrofil and limfosit infiltration
Inflamation

Supportive Test
Laboratorium :

Complete Blood Count

Leukocytosis
Urinalysis
Hematuria + proteinuria
IgA serum level increased
Skin Biopsy
Leukocytoclastic vaskulitis

Radiography

Chest and abdominal Imaging

Therapy
Bed rest + Supportive care
Self Limiting disease
(resolve in 6 8 weeks)
Immunosuppresan
Cyclophosphamide
Corticosteroid
NSAID (Non Steroid Anti Inflamation Drugs)
- Dapsone

Idiopathic
Trombocytopenic
Purpura
Bleeding, petechie / ekimosis on
the skin or(ITP)
mucous membrane

with trombocyte reduction which

is usually idiopathic.

Classification
Acute
: children 2-8 years old,
85 90%
Chronic
: adults 15-50 years
old, 10 15%

Acute ITP
Incidence -> age : 2 8 years old
Female > Male = 4 : 3 or 2 : 1

Patomechanism
Autoantibody IgG binding on the platelet surface

Platelet sensitated

Macrofage RES fagocytosis

( in hepar and spleen)

Signs and Symptoms

Bleeding -> skin and mucous
membrane (petechie, melena,
epitaksis, hematuri), cerebral
bleeding at severe trombocytopeni.
Tiredness, weight loss, limph gland
enlargement
Feeling of saturated stomach,
stomach pain

Tests and Examinations

Peripheral blood test = trombocytopenia,
normocytic, normal leucocyte and
ascending on heavy bleeding
Bone marrow test = commonly normal,
increasing of megakariocyte
Reduction of coagulation retraction
Extended bleeding time
Shorter PCT
Turniket Test (+)

Treatment
Some patients -> Spontaneous
remision
Severe -> corticosteroid
Intravenous heparin
Transfusion of trombocyte
suspension

Ethiology
Idiopathic
Hipersplenism, viral infection, food,
Drugs : asetosal, paraaminosalisilat,
fenulbutasol, diamoks, kina, sidermit
Chemical materials
Malnutrition -> lack of maturation
factor