Dr. Ali Mala Ali: Four cases of natural bleeding do not indicate a diagnosis of "hemophilia"
Dr. Wala’a Hafiz: Blood clotting disorders may appear to some as merely a common term, but in reality, they are conditions that demand attention due to the potential health complications they can cause if not diagnosed and managed properly. While many associate blood clotting disorders solely with bleeding, their causes extend to genetic disorders, acquired diseases, and the use of certain medications. In this interview, Dr. Ali Mla Ali, Consultant of Hematology, Oncology, and Coagulation, sheds light on the concept of blood clotting disorders, their main types and causes, the misconceptions that may delay their detection, as well as clarifying the difference between normal and abnormal bleeding, and ways to live with the condition and prevent its complications.
Speaking to Al-Qabas, Dr. Ali Mla Ali stated that many people may live for years without knowing they have a mild blood clotting disorder, explaining that this is due to the body’s ability to maintain a delicate balance between blood clotting and bleeding most of the time, albeit at a slower-than-normal rate. He added that this balance may be disrupted and become more apparent when the body is subjected to what is known as a "test" or "challenge" to the clotting system, such as surgical procedures, tooth extractions, accidents—God forbid—or during childbirth.
He clarified that this type of blood clotting disorder is described as "silent" because it often does not prevent the affected individual from carrying out their daily life or usual activities, and therefore may remain undetected for years. The likelihood of suspecting the condition increases when there is a family history of blood clotting or bleeding disorders.
Regarding the difference between "blood clotting disorder" as a disease and the use of blood thinners such as aspirin and warfarin, Dr. Ali Mla Ali explained that the term "blood clotting disorder" is generally used to refer to a disorder or disease that affects the blood’s ability to clot, whereas blood thinners are medications prescribed to increase blood fluidity in individuals with a history of blood clots or an elevated risk of developing them. He added that many people confuse the two conditions because the final outcome in both cases is the same: increased blood fluidity and delayed cessation of bleeding. However, the underlying causes are entirely different.
He emphasized that the fundamental rule is to distinguish between blood clotting resulting from a genetic or pathological disorder, and blood clotting resulting from the consumption of anticoagulants or blood thinners, as each condition has its own causes, diagnostic methods, and treatment approaches.
**Bleeding episodes that may be normal**
Regarding recurrent nosebleeds in children and young adults, Dr. Ali Mla Ali clarified that this may be normal in some cases, while in others it may indicate a clotting disorder. He stressed that differentiation depends on the pattern, location, volume of bleeding, and accompanying symptoms. He stated that 80% to 90% of bleeding cases are normal and do not indicate an underlying disease. The most prominent examples include:
1. **Recurrent nosebleeds (epistaxis):** This is considered normal if it occurs during winter, due to dry air, or frequent nose rubbing, and stops within 5 to 10 minutes with direct pressure, without accompanying bruising or bleeding elsewhere in the body. He explained that the cause lies in the fragility and sensitivity of the blood capillaries at the front of the nose.
2. **Gum bleeding during teeth cleaning:** This is normal if it results from gum inflammation due to plaque buildup and disappears after gum treatment and teeth cleaning by a dentist. However, if the gums are healthy and the cleaning technique is correct, recurrent bleeding warrants medical evaluation.
3. **Bruises in active children:** Small bruises appearing on the knees or hands as a result of play and daily activity are normal, especially if they are limited and resolve within about a week.
4. **Heavy menstrual flow at the onset:** Menstrual periods may be heavy or irregular during the first one or two years after menarche in girls, which is considered normal due to hormonal instability during this phase. However, if the bleeding is severe or persists abnormally, it may indicate a problem requiring a doctor’s visit.
**Signs warranting suspicion of bleeding disorders**
Conversely, Dr. Ali Mla Ali stressed that some bleeding cases may indicate a clotting disorder and require necessary medical tests. He said: "One should suspect a bleeding disorder if one or more of the following signs appear:"
1. **Regarding the pattern of bleeding: "Bleeding from minor injuries"**
* Continued bleeding from a minor wound for 20 to 30 minutes without stopping.
* Bleeding continuing for two or three days after a tooth extraction.
* Bleeding lasting longer than expected after a child’s circumcision or tonsillectomy.
* Bleeding recurring after it had stopped for a day or two.
2. **Regarding the location of bleeding: "Unusual sites"**
* Bruises appearing on the back, abdomen, or buttocks without a clear cause.
* Large bruises disproportionate to the severity of the injury or blow.
* Appearance of small red spots under the skin, especially in the chest area.
* Presence of blood in urine or stool without hemorrhoids or inflammation to explain it.
3. **Regarding the volume of bleeding: "More than normal"**
* Heavy menstrual flow requiring changing sanitary pads every hour.
* Passage of large blood clots or menstrual periods lasting more than seven days.
* Nosebleeds that are difficult to stop and require cauterization or nasal packing by a doctor.
* Severe and recurrent gum bleeding despite healthy teeth and gums and good oral hygiene.
4. **Family history**
* Presence of a family member, such as a father, mother, uncle, or cousin, diagnosed with hemophilia or a bleeding disorder, or with a history of abnormal bleeding after surgical procedures.
* Death of a family member due to bleeding following a minor surgical procedure or limited medical intervention.
Dr. Ali emphasized that the appearance of these signs does not necessarily mean a bleeding disease is present, but it warrants a doctor’s visit for evaluation and necessary tests, aiming for early diagnosis and avoiding potential complications.
**An important indicator for detecting hereditary bleeding diseases**
Dr. Ali Mla Ali, Consultant of Hematology, Oncology, and Coagulation, pointed out that heavy menstrual flow may be an important indicator for detecting some hereditary bleeding disorders, primarily von Willebrand disease, noting that many cases remain undiagnosed for years. He said: "The problem lies in the fact that 60% to 70% of girls with von Willebrand disease are diagnosed late, due to their belief that heavy menstrual flow is normal for all girls, which delays seeking medical consultation and undergoing necessary tests."
He explained the link between heavy menstrual flow and bleeding disorders by stating: "During menstruation, the uterine lining sheds, and blood exits through tiny blood capillaries. To stop the bleeding, the body requires rapid and coordinated action of clotting factors and platelets. When there is a deficiency, even if slight, in von Willebrand factor or Factor VIII, blood clots form slowly, causing bleeding to last longer and be heavier."
**Supplements and natural herbs**
Dr. Ali Mla Ali warned that excessive consumption of certain dietary supplements and natural herbs may increase the risk of bleeding without many people realizing it, stressing that the belief that everything "natural" is completely safe is incorrect. Conversely, he noted that some supplements are not typically known to increase bleeding risk, such as vitamin D, vitamin B12, magnesium, and iron. However, he emphasized the necessity of taking them at recommended doses and under medical supervision when needed, to avoid any side effects or potential drug interactions.
**Signs requiring emergency care**
Dr. Ali Mla Ali stressed that internal bleeding is one of the most dangerous types of bleeding, as it may occur silently without any visible wound, delaying its detection and increasing the risk of complications. He said: "A person may appear normal externally, while internal bleeding is occurring unseen. When symptoms such as extreme fatigue, dizziness, and pallor begin to appear, the patient may have lost a significant amount of blood without realizing it."
He added that there are several warning signs that require immediate medical attention, the most prominent being:
1. **Bleeding in the abdomen or chest**
* Severe and sudden abdominal pain, especially after an accident or blow, even if it appears minor.
* Rapid abdominal swelling or difficulty breathing.
* Pain in the left shoulder after a blow to the abdomen, which may indicate a ruptured spleen.
* Dizziness upon standing, fainting, rapid heartbeat, or cold and clammy skin.
2. **Bleeding in the brain**
* Sudden and severe headache, described as the "worst headache of one’s life," especially after a head injury.
* Repeated vomiting, extreme drowsiness, or difficulty waking the affected person.
* Weakness on one side of the body, speech disturbances, or unequal pupil sizes.
He indicated that even if the affected person regains consciousness after falling on their head and appears to be in good condition, they should be monitored for 24 hours, as bleeding symptoms may be delayed in appearing for 6 to 12 hours.
3. **Bleeding in the gastrointestinal tract**
* Vomiting bright red blood, or vomit resembling "coffee grounds."
* Passing black, tarry stools, or red blood mixed with stool.
* Severe abdominal pain accompanied by dizziness and pallor.
4. **General signs of internal bleeding**
Dr. Ali Mla Ali stressed that the presence of two or more of the following symptoms warrants immediate前往 the emergency department:
* Dizziness or feeling faint upon standing.
* Rapid heartbeat or rapid breathing at rest.
* Sudden pallor with cold sweating without a clear cause.
* Extreme and sudden exhaustion preventing the person from performing their usual activities or even lifting their head off the pillow.
