Hemorrhage, vitamin

Vitamin K deficiency results in a tendency to hemorrhage. Vitamin K is synthesized by the normal intestinal flora. Deficiencies occur in infants because fetal stores are low and the fetal gut is sterile. In adults, deficiencies result from long-term administration of antibiotics... 

In studies in Denmark in the 1920s, Henrik Dam noticed that chicks fed a diet extracted with nonpolar solvents developed hemorrhages. Moreover, blood taken from such animals clotted slowly. Further studies by Dam led him to conclude in 1935 that the antihemorrhage factor was a new fat-soluble vitamin, which he called vitamin K (from koagulering, the Danish word for coagulation ). 

Dicoumarol is found in sweet clover and can cause hemorrhaging in cattle because of its anticoagulant action. It acts as a vitamin K antagonist and has served as a model for the development of warfarin and related anticoagulant rodenticides. 

Warfarin and the second-generation superwarfarins are ARs that have a structural resemblance to dicoumarol and vitamin K. They act as vitamin K antagonists, thereby retarding or stopping the carboxylation of clotting proteins in the hepatic endoplasmic reticulum. The buildup of nonfunctional, undercarboxylated clotting proteins in the blood leads eventually to death by hemorrhaging. 

The last of the fat-soluble vitamins to be identified was vitamin K, found by Dam to be an anti-hemorrhagic factor for young chicks, distinct from vitamin C. Its structure was determined by Dam in collaboration with Karrer. Interest in the vitamin was intensified when it was discovered (Link, 1941) that dicoumarol, present in spoiled sweet clover, was the agent producing hypothrombinemia (giving prolonged blood-clotting time) in cattle. Since vitamin K is structurally similar to dicoumarol, the vitamin was presumptively implicated in thrombin formation. This has been fully substantiated by recent work on the role of vitamin K in the synthesis of prothrombin in the liver. 

Toxicology. Pindone is a vitamin K antagonist and causes inhibition of prothrombin formation, which results in hemorrhage. 

There are no reports of effects in humans. In rats, the ingestion of a single large dose of pindone causes rapid death due to pulmonary and visceral congestion without hemorrhage and may not be related to vitamin K... 

Parenteral Anticoagulant-induced prothrombin deficiency hypoprothrombinemia secondary to conditions limiting absorption or synthesis of vitamin K (eg, obstructive jaundice, biliary fistula, sprue, ulcerative colitis, celiac disease, intestinal resection, cystic fibrosis of the pancreas, regional enteritis) drug-induced hypoprothrombinemias due to interference with vitamin K metabolism (eg, antibiotics, salicylates) prophylaxis and therapy of hemorrhagic disease of the newborn. 

Pharmacokinetics Phytonadione is only absorbed from the Gl tract via intestinal lymphatics in the presence of bile salts. Although initially concentrated in the liver, vitamin K is rapidly metabolized, and very little tissue accumulation occurs. Parenteral phytonadione is generally detectable within 1 to 2 hours. Phytonadione usually controls hemorrhage within 3 to 6 hours. A normal prothrombin level may be obtained in 12 to 14 hours. Oral phytonadione exerts its effect in 6 to 10 hours. 

The answer is B. The patient shows many signs of vitamin G deficiency or scurvy, which is seen most frequently in infants, the elderly, and in alcoholic patients. Particularly indicative of vitamin C deficiency are the multiple small hemorrhages that occur under the skin (petechiae) and nails and surrounding hair follicles. Bleeding gums are a classic indicator of scurvy. 

Deficiency may occur in infants if no fruits or vegetables are added to their milk formulas. In alcoholics, and in elderly subjects who consume inadequate diets vitamin C deficiencies are frequent. Severe ascorbic acid deficiency is characterized by the syndrome known as scurvy. Its manifestations are generally based on a loss of collagen. Symptoms include hemorrhages, loosening of teeth. In children cellular changes in the long bones occur. 

Hypoprothrombinemia may occur in malabsorption syndromes and also the use of broad-spectrum antibiotics may produce a hypoprothrombinemia that responds readily to small doses of vitamin K. In premature infants and in infants with hemorrhagic disease of the newborn the use of vitamin K may be indicated. However, the main indication for the use of vitamin K is to antagonize the anticoagulant activity of coumarins. Oral absorption of phytonadione and the menaquinones is by the lymph while menadione and its water-soluble derivatives are absorbed directly. The absorption of phytonadione is energy-dependent and saturable. Intravenous administration of phytonadione has produced flushing, dyspnea, chest pains, and cardiovascular collapse. 

Another concern in infants of mothers with epilepsy is a serious hemorrhagic disorder that is associated with a high (25-35%) mortality. This probably results from the finding that many AEDs can act as competitive inhibitors of vitamin K-dependent clotting factors. The competitive inhibition can be overcome by the administration of oral vitamin K supplements to the mother during the last week or 10 days of pregnancy. 

In general, ethanol in low to moderate amounts, is relatively benign to most body systems. A moderate amount of ethanol causes peripheral vasodilation, especially of cutaneous vessels, and stimulates the secretion of salivary and gastric fluids the latter action may aid digestion. On the other hand, ethanol consumption in high concentrations, as found in undiluted spirits, can induce hemorrhagic lesions in the duodenum, inhibit intestinal brush border enzymes, inhibit the uptake of amino acids, and limit the absorption of vitamins and minerals. In addition, ethanol can reduce blood testosterone levels, resulting in sexual dysfunction. 

The dehciency disease associated with a lack of ascorbic acid is called scurvy. Early symptoms include malaise and follicular hyperkeratosis. Capillary fragility results in hemorrhages, particularly of the gums. Abnormal bone and tooth development can occur in growing children. The body s requirement for vitamin C increases during periods of stress, such as pregnancy and lactation. 

C. Early symptoms of vitamin C dehciency, or scurvy, include malaise. Hemorrhages, especially of the gums, may result from capillary fragihty. 

Bleeding complications ranging from local ecchymoses to major hemorrhage may occur. Drug should be discontinued immediately and vitamin K or phytonadione administered. Mild hemorrhage 2.5-10 mg PO, IM, or IV. Severe hemorrhage 10-15 mg IV and repeated q4h, as necessary. 

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