Bleeding is a common presenting problem at the time of initial diagnosis in several types of cancers. It is less frequent in the palliative care setting and has been estimated to affect 6–10% of patients. Although they are less frequent, these bleeding events can be frightening and dramatic for the patients, their families, and healthcare professionals, especially if the hemorrhaging is massive.

Clinical approach

In the palliative care setting, management of bleeding requires consideration of many factors. The clinician has not only to consider the underlying cause, the clinical presentation, and the severity of the event, but he also needs to take into account other salient factors such as the setting of care, the availability of various resources, the overall disease burden, the life expectancy, the patient's overall quality of life, and the wishes of the patient and family.

Malignancies involving the upper and lower gastrointestinal tracts, lungs, kidneys, bladder, and female genital tract can produce massive bleeds that present as hematemesis, hematochezia, melena, hemoptysis, hematuria, and vaginal bleeding, respectively.

These hemorrhages can result in catastrophic events that may cause hypovolemic shock and are immmediately life threatening. They can also give rise to chronic, low-volume bleeding or occasional hemorrhages of low to medium intensity.

Systemic disorders such as coagulation and platelet abnormalities, and disseminated intravascular coagulation may cause hemorrhages or increase their risk. Clotting and fibrinolysis abnormalities are thus detectable in up to 50% of palliative care patients.