| Ch 16 | Page 8 / 16 | |
| Urgences cancérologiques |
Haemorrhages | |
Haemorrhage is the third most frequent cause of cancer death (after organ failure due to tumour invasion and infectious complications) and the second among patients with haematological disorders.
The reasons for bleeding are numerous:
- Lesion of a vascular vessel (capillary or larger vessel),
- Diffuse superficial bleeding which occurs after thrombocytopenia (iatrogenic or not), particularly in the case of associated infection,
- Bleeding related to abnormally low level of coagulation factors (intravascular coagulation).
Although these haemorrhages are quite frequent (either due to cancer, haemostasis abnormalities or local ulcerations), they are rarely massive enough to threaten the patient’s life.
In the stomach, the most frequent cause is haemorrhagic gastritis and peptic ulcer, which complicate treatment by anti-inflammatory drugs, corticosteroids or occurring during septicaemia with renal and hepatic insufficiency.
Direct involvement of the digestive wall is rare (except in the case of primitive lesions). The famous Mallory-Weiss syndrome (haemorrhage due to intense vomiting) is rarely severe.
Haemorrhage of the inferior digestive tract is most often related to a benign intestinal lesion or to treatment side-effects (such as rectal haemorrhage after radiotherapy for gynaecological or urinary cancers). These haemorrhages are difficult to treat (local corticosteroids, cauterisation with laser beam).
Massive bronchial haemorrhage (hemoptysis) is rarely involved in patient death in lung cancer. The flooding of the bronchial tubes is far more life-threatening than the actual quantity of blood lost.
The most frequently concerned cancer is epidermoid lung cancer since it invades blood vessels and is highly necrotic.
Another frequent cause of hemoptysis is pulmonary aspergillosis which often occurs in immunodeprived patients (after prolonged chemotherapy).
More rarely, hemoptysis is related to therapy (laser, endobronchial brachytherapy).
Treatment includes very simple measures such as adopting a semi-seated position, oxygenation, aspiration, and a rapid search for the aetiology (bronchosopy if the patient’s status permits).
In terminal hemoptysis, patient anxiety should be relieved (subcutaneous morphine, midazolam), and a carer/family member should remain at the patient’s bedside until sleeping.
If no efficient aetiological treatment is possible (surgery for instance), various techniques have been proposed such as a Fogarty catheter, arterial embolisation, radiotherapy or laser beam.
Rupture of the internal carotid artery remains a frequent complication in head and neck cancers.
The main reasons for rupture are post-surgical infection, ligature failure, wound breakdown after radiotherapy and direct tumour invasion of the artery. With the recent progress in surgery and radiotherapy, this complication is becoming rarer.
This rupture never occurs on a healthy mucosa or skin. Most often, a wound infection or tumour infection, exposure of a vessel or vessel necrosis with small revealing haemorrhages are present.
The prophylactic ligature of the internal carotid prevents massive haemorrhage with a potential risk of underlying cerebral ischemia. It avoids the necessity for urgent carotid ligature if massive haemorrhage does occur.
This cataclysmal haemorrhage is a most terrifying event for the patient, the family but also for every unprepared caregiver.
When this event is expected and when no ligature is feasible, the therapeutic procedure should be prepared, in particular the sedative hypnotic drugs to be infused when the cataclysm occurs as well as the thick dressing requried to hide the massive bleeding from the patient and his/her family. In terminal haemorrhage, treatment simply consists in blood vessel compression and patient sedation. Death occurs in a few minutes.
If the haemorrhage occurs when therapeutic solutions are still possible (such as salvage surgery), then treatment should be active with compression and emergency ligature of the carotid artery, with the risk of vascular complications (hemiplegia). A programmed carotid ligature is always easier and more efficient than an emergency ligature.
They occur when a tumour of the base of the tongue erodes the small branches of the external carotid artery.
They require the ligature of one or both external carotid arteries with the constant necessity to maintain the airways free for breathing.
Occasionally, as in internal carotid rupture, massive oral haemorrhage is a terminal event. Patient sedation should be very quickly administered in order to avoid suffocation by patient’s own blood.
Epistaxis (nose bleeding) is very frequent during aplastic chemotherapies especially during leukaemia induction treatment.
Epistaxis is rarely life-threatening and spontaneously stops with nose compression or nose packing.
When epistaxis is posterior, it requires posterior packing during pharyngoscopy.
Bleeding from ethmoidal tumours generally requires adequate surgical treatment or embolisation.
It is a rare event which occurs:
- In massive bladder involvement by a bladder or prostate cancer
- After toxic chemotherapy (alkylating agents such as cyclophosphamide or ifosfamide in relation to their bladder-toxic metabolite acrolein),
- After BCG cystitis for a superficial bladder tumour,
- After post-radiotherapy cystitis (related to the dose delivered to the bladder)
- In case of various severe coagulation disorders.
A massive bladder haemorrhage requires the maintenance of a correct urinary circuitry in order to avoid hydronephrosis: fitting of a double tract urinary catheter, bladder washing, hydration, transfusions and cystocopy to confirm diagnosis.
In relapsing massive badder haemorrhages, laser beam, haemostatic irradiation, hypogastric artery embolisation, hypogastric artery surgical ligature or sometimes haemostatic cystectomy have been proposed.
It is a rare complication due to the invasion of the femoral artery by a metastatic inguinal node from the penis, vulva or a tumour from an inferior limb.
Generally these nodes have been irradiated and suturing the bleeding femoral artery is almost impossible.
Thus, as for carotid artery ruptures, clear measures should be taken in order to minimise the dramatic and traumatic nature of patient death.
|
