Table of ContentsView All
View All
Table of Contents
Causes
General Signs
Diagnosis
Complications
High Risk Groups
Treatment
Prognosis
When to See a Doctor
Internal bleeding symptoms include severe pain, dizziness, swelling, and coughing up blood, depending on the affected area and the rate of blood loss. You might suspect internal bleeding if you experience unexplained weakness, persistent pain, or signs like swelling and discoloration without an obvious injury.
Survival depends on the severity and location, but immediate medical attention is crucial as untreated internal bleeding can be life-threatening.
In some cases, internal bleeding can manifest with silent or very subtle symptoms, like fatigue or mild discomfort, especially if the bleeding is slow. That said, symptoms may not always match the severity of blood loss. While minor cases might resolve naturally, internal bleeding usually demands medical intervention and may require surgery or blood transfusions.
Verywell / JR Bee
Trauma
Trauma is one of the more common causes of internal bleeding. It can include various types of injuries:
Aneurysm
Aneurysms can occur in any blood vessel, although they are more common in the brain (cerebral aneurysm) or the aorta, either in the chest (ascending or descending thoracic aortic aneurysm) or abdomen (abdominal aortic aneurysm).
Bleeding Disorders
Bleeding disorderssuch ashemophiliacan increase a person’s risk of bleeding, including internal bleeding. This is caused when blood does not clot as it should, either due to a lack of blood cells called platelets or proteins called clotting factors.
The overuse of certain drugs can have the same effect. This includes blood thinners like warfarin and anti-platelet drugs like Plavix (clopidogrel). Even nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and Advil (ibuprofen) can cause internal bleeding if used in excess, especially if you have apeptic ulceror any other condition that causes gastric (stomach) bleeding.
Hemorrhagic Fevers
A less common cause of internal bleeding is viral hemorrhagic fevers. Certain viruses can cause small blood clots in blood vessels throughout the body. By doing so, there are fewer platelets available to stop bleeding.
Common symptoms include vomiting, diarrhea, muscle pain, tiny red or purple spots on the skin (calledpetechiae), bleeding, and a drop in blood pressure.
Many viral diseases can cause internal bleeding, most of which are confined to Africa. These include:
Signs and Symptoms
The symptoms of internal bleeding do not always correspond to the severity of the bleeding.
For example, large amounts of blood may be lost following an abdominal or kidney injury before symptoms appear. By contrast, even small amounts of bleeding in parts of the brain can cause significant symptoms and even death.
In trauma cases, the initial lack of signs or symptoms does not mean that a person is in the clear. It is only later that symptoms may develop and turn severe.
Symptoms of internal bleeding include:
Lightheadedness
Lightheadedness and dizziness are common with rapid or massive blood loss. In cases where the blood loss is gradual, lightheadedness may only occur when a person tries to stand and the blood pressure drops (orthostatic hypotension).
Pain
Pain is a common symptom of internal bleeding, as blood irritates tissues. The pain may be confined to the bleeding area in some parts of the body, such as the chest. With others, like the abdomen, the pain may be felt in other parts of the body (known as referred pain). For instance, bleeding near thediaphragmis often felt in the shoulder.
Guarding
It is common for people to display guarding when internal bleeding occurs. Guarding is an unconscious attempt to keep a person from touching a part of the body that is tender or injured.
Shortness of Breath
Shortness of breathcan be a symptom of internal bleeding in any body part. With blood loss, fewer red blood cells carry oxygen to tissues, which causes trouble breathing.
Tingling in Hands and Feet
With blood loss, the body often “clamps down” on vessels in the limbs to re-direct blood to essential organs. Losing oxygen to the limbs can causetingling in the hands or feet. Internal bleeding can also causehyperventilation(rapid breathing) as the body tries to raise oxygen levels.
Changes in Vision
Vision changes are common with internal bleeding. They can occur before “blacking out” when the blood loss is rapid or severe. Other changes may be due to abrain bleed, in which blurred anddouble visionare common.
Nausea or Vomiting
Nausea and vomiting may occur due to blood loss or in response to pain. These symptoms are expected when the bleeding is in the digestive tract or the brain.
Profuse Sweating
Heavy sweating for no apparent reason (calleddiaphoresis) can occur when blood loss is sudden or severe. The loss of blood can cause a rapid change in body temperature, which can cause sudden, extreme sweating. People often describe this as “breaking out in a cold sweat.”
Bruising
Bruising can sometimes indicate where a bleed is occurring. Bruising around the navel, referred to as aCullen’s sign, suggests bleeding in the belly. Bruising on the flank, known as Grey Turner’s sign, can occur when bleeding in the abdomen orretroperitonealspace (where the kidneys are located). Extensive bruising can occur with fractures.
Change in Mental Status
A change in mental status, including confusion and disorientation, is a sign that a lot of blood has been lost. This can include a total loss of consciousness. A change in mental status is a sign of a medical emergency.
Site-Specific Symptoms
Internal bleeding in specific parts of the body may lead to distinct symptoms. These include:
Brain
Chest
Bleeding in the chest can cause shortness of breath, a gasping cough, andhemoptysis(coughing up blood). Coughing up even just a teaspoon of blood is a medical emergency. Coughing up to 1/4 cup of blood or more is linked to a high risk of death.
Bleeding around the heart (known aspericardial effusion) can restrict the heart’s motion. This can lead to life-threateningcardiac tamponade.
Abdomen
Bleeding into the abdomen can cause swelling along with diffuse pain. When a healthcare provider places a stethoscope on the stomach,bowel sounds may be absent. Bruising around the navel or flank strongly suggests internal bleeding.
Bleeding into the esophagus or stomach can lead to bloody vomit, while bleeding in the lower digestive tract may cause rectal bleeding orbloody stools.Bleeding in the kidneys or bladder can causeblood in the urine.
It is possible to have internal bleeding with no symptoms if the bleeding is slow or the cause is non-traumatic. An example includes taking blood thinners while you have a peptic ulcer, which can promote bleeding and only cause symptoms as the condition worsens. Prior to this, the only sign may be dark stools.
Bones, Joints, and Muscles
Internal bleeding is diagnosed with lab tests and imaging tools.
Lab Tests
There are a few different lab tests that can detect internal bleeding. A blood test can show if someone has anemia (low red blood cells) due to blood loss. A stool sample can be tested for occult blood (blood in the stool).Lab tests can also test for bleeding disorders and other illnesses.
Imaging Tests
In cases of severe trauma, such as a bad car accident, healthcare professionals might do a CT scan of the person from head to toe, known as a pan-scan, to look for injuries and bleeding.
However, imaging will usually be localized to the region that experienced injury or shows signs of bleeding. Imaging tests, such as X-rays, CT scans, ultrasounds, angiograms, and endoscopy, can help pinpoint the location of the bleeding.
But other complications can lead to death or permanent injury:
Shock
Most often, the signs of shock (including clammy skin, rapid heartbeat, and difficulty breathing) occur when a person has lost between 10% and 15% of their blood volume.
Organ Failure or Damage
Some organs are more sensitive to blood loss and shock than others. In the heart and kidneys, for instance, the lack of blood flow causes tissues to die quickly, a process called necrosis. This can reduce the function of these organs, often permanently, leading to organ failure.
The same can occur with brain bleeds, in which tissue death can lead to paralysis, vision loss, personality changes, memory loss, and problems swallowing.
Special Populations
Bleeding can raise particular concerns in different groups of people, most specifically children and pregnant people.
Children
Unlike adults, children may not be able to describe their symptoms. Instead of complaining of pain, they may become fussy, cry continually, or become difficult to console. They may also have a poor appetite or refuse to eat.
Changes in mental status are also common clues. For instance, a child who normally loves to play may become lethargic. Vision changes can cause a child to bump into walls or miss objects they are reaching for.
Pregnancy
Early on in pregnancy, bleeding may be the sign of a miscarriage or a more potentially deadly condition called anectopic pregnancy. Later on,placenta previa, placental abruptions, or uterine rupture can cause internal bleeding.
Complications like these often cause vaginal bleeding, but this is not always the case. In some cases, the bleeding may be concealed behind the placenta.This can increase the risk of a late diagnosis and death.
How Internal Bleeding Is Treated
Internal bleeding treatment focuses on stopping blood loss, stabilizing the affected person, and addressing the cause. Care begins with assessing the severity and location of the bleeding. Mild cases may resolve on their own with monitoring, but significant bleeding often requires urgent medical intervention.
In a hospital setting, imaging tests like ultrasounds, CT scans, or MRIs are used to pinpoint the source of bleeding. For severe cases, surgical procedures, such aslaparotomyor endoscopy, are commonly performed to stop the bleeding. Treatments may include repairing damaged blood vessels, removing ruptured organs, or using techniques like cauterization or embolization to seal off the source.
Clotting support is also critical. Medications such as tranexamic acid (TXA) or clotting factor replacements may be given, alongsideblood transfusionsto replenish lost blood. For people taking blood thinners, antidotes may be administered to counteract their effects. Rapid medical care is essential, as untreated internal bleeding can lead to life-threatening complications.
Can You Stop Internal Bleeding Naturally?Some very mild cases of internal bleeding may resolve naturally if the body forms clots to stop the bleeding. However, there are no reliable at-home methods for stopping internal bleeding, as it often requires specialized care to locate and control the source. In most cases, hospital treatment is critical to prevent severe complications and improve the chances of survival.
Can You Stop Internal Bleeding Naturally?
Some very mild cases of internal bleeding may resolve naturally if the body forms clots to stop the bleeding. However, there are no reliable at-home methods for stopping internal bleeding, as it often requires specialized care to locate and control the source. In most cases, hospital treatment is critical to prevent severe complications and improve the chances of survival.
The chances of surviving internal bleeding depend on how severe the bleeding is, where it’s happening in the body, and how quickly it’s treated.
Even though healthcare providers have made improvements in treating trauma patients, uncontrolled bleeding is still a major cause of death after severe injuries. In some cases, death can happen very quickly—within about an hour and a half of arriving at the hospital—if the bleeding is not stopped fast.
Internal bleeding can cause serious problems, such as shock and organ damage. If the bleeding affects important organs like the brain, heart, or lungs, it can cause long-term damage and make survival more difficult. The sooner treatment is started, the better the chance of survival, especially if healthcare providers can find and stop the bleeding quickly.
When to See a Healthcare Provider
Internal bleeding can be life-threatening and requires immediate action to prevent death or irreversible organ damage.
It is essential to call 911 if you or someone you know shows signs of internal bleeding, including:
Summary
Symptoms include pain, lightheadedness, nausea or vomiting, bruising, cold sweat, tingling hands or feet, vision changes, confusion, and fainting. Complications may include shock, organ damage or failure, and death.
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Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Apollo Hospitals.Hemorrhage: Types, causes, symptoms, treatment, and more.Latif R, Clifford S, Baker J, et al.Traumatic hemorrhage and chain of survival.Scand J Trauma Resusc Emerg Med. 2023;31(1):25. doi:10.1186/s13049-023-01088-8Varma D, Brown P, Clements W.Importance of the mechanism of injury in trauma radiology decision-making.Korean Journal of Radiology. 2023;24(6):522. doi:10.3348/kjr.2022.0966Mathur A, Mohan V, Ameta D, Gaurav B, Haranahalli P.Aortic aneurysm.J Transl Int Med. 2016;4(1):35-41. doi:10.1515/jtim-2016-0008American Heart Association.Types of aneurysms.National Heart, Lung & Blood Institute.What are bleeding disorders.Tai FWD, McAlindon ME.Non-steroidal anti-inflammatory drugs and the gastrointestinal tract.Clin Med (Lond). 2021;21(2):131-134. doi:10.7861/clinmed.2021-0039Fhogartaigh CN, Aarons E.Viral haemorrhagic fever.Clin Med (Lond).2015 Feb;15(1):61–6. doi:10.7861/clinmedicine.15-1-61Arnold AC, Raj SR.Orthostatic hypotension: a practical approach to investigation and management.Can J Cardiol. 2017;33(12):1725-1728. doi:10.1016/j.cjca.2017.05.007Sefton EM, Gallardo M, Kardon G.Developmental origin and morphogenesis of the diaphragm, an essential mammalian muscle.Dev Biol. 2018;440(2):64-73. doi:10.1016/j.ydbio.2018.04.010Olugbade T, Bianchi-Berthouze N, Williams AC de C.The relationship between guarding, pain, and emotion.Pain Rep. 2019;4(4):e770. doi:10.1097/PR9.0000000000000770Armstrong RA.Visual problems associated with traumatic brain injury.Clin Exp Optom. 2018;101(6):716-726. doi:10.1111/cxo.12670Green-Hopkins I, Monuteaux MC, Lee LK, Nigrovic LE, Mannix R, Schutzman SA.Use of ondansetron for vomiting after head trauma: does it mask clinically significant traumatic brain injury?Pediatr Emerg Care. 2020;36(8):e433-e437. doi:10.1097/PEC.0000000000001315Wright WF.Cullen sign and grey turner sign revisited.J Am Osteopath Assoc. 2016;116(6):398-401. doi:10.7556/jaoa.2016.081National Institute of Neurological Disorders and Stroke.Traumatic brain injury (TBI).Kathuria H, Hollingsworth H, Vilvendhan R, Reardon C.Management of life-threatening hemoptysis.J Intensive Care. 2020 Apr;8(1):23. doi:10.1186/s40560-020-00441-8Cedars Sinai.Cardiac tamponade.Zaborski D, Halczak M, Grzesiak W, Modrzejewski A.Recording and analysis of bowel sounds.Euroasian J Hepatogastroenterol. 2016 Jul;5(2):67-73. doi:10.5005/jp-journals-10018-1137National Institute of Diabetes and Digestive and Kidney Diseases.Symptoms & causes of GI bleeding.Penn Medicine.Hematuria.NYU Langone Health.Diagnosing compartment syndrome.National Institute of Diabetes and Digestive and Kidney Issues.Diagnosis of GI Bleeding.Harntaweesup S, Krutsri C, Sumritpradit P, et al.Usefulness and outcome of whole-body computed tomography (Pan-scan) in trauma patients: A prospective study.Ann Med Surg (Lond). 2022;76:103506. doi:10.1016/j.amsu.2022.103506National Institute of Diabetes and Digestive and Kidney Diseases.Diagnosis of GI bleeding.Standl T, Annecke T, Cascorbi I, R. Heller A, Sabashnikov A, Teske W.The nomenclature, definition and distinction of types of shock.Dtsch Arztebl Int. 2018;115(45):757-768. doi:10.3238/arztebl.2018.0757Hooper N, Armstrong TJ.Hemorrhagic shock. In:StatPearls [Internet].Magid-Bernstein J, Girard R, Polster S, et al.Cerebral hemorrhage: pathophysiology, treatment, and future directions.Circ Res. 2022;130(8):1204-1229. doi:10.1161/CIRCRESAHA.121.319949Children’s Hospital of Philadelphia.Bleeding in pregnancy/placenta previa/placental abruption.Bumrungrad International Hospital.Vaginal bleeding in late pregnancy.CARE Hospitals.Internal bleeding: Signs, symptoms, causes & treatment.Maegele M.The diagnosis and treatment of acute traumatic bleeding and coagulopathy.Dtsch Arztebl Int. 2019 Nov;116(47):799–806. doi:10.3238/arztebl.2019.0799
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
Apollo Hospitals.Hemorrhage: Types, causes, symptoms, treatment, and more.Latif R, Clifford S, Baker J, et al.Traumatic hemorrhage and chain of survival.Scand J Trauma Resusc Emerg Med. 2023;31(1):25. doi:10.1186/s13049-023-01088-8Varma D, Brown P, Clements W.Importance of the mechanism of injury in trauma radiology decision-making.Korean Journal of Radiology. 2023;24(6):522. doi:10.3348/kjr.2022.0966Mathur A, Mohan V, Ameta D, Gaurav B, Haranahalli P.Aortic aneurysm.J Transl Int Med. 2016;4(1):35-41. doi:10.1515/jtim-2016-0008American Heart Association.Types of aneurysms.National Heart, Lung & Blood Institute.What are bleeding disorders.Tai FWD, McAlindon ME.Non-steroidal anti-inflammatory drugs and the gastrointestinal tract.Clin Med (Lond). 2021;21(2):131-134. doi:10.7861/clinmed.2021-0039Fhogartaigh CN, Aarons E.Viral haemorrhagic fever.Clin Med (Lond).2015 Feb;15(1):61–6. doi:10.7861/clinmedicine.15-1-61Arnold AC, Raj SR.Orthostatic hypotension: a practical approach to investigation and management.Can J Cardiol. 2017;33(12):1725-1728. doi:10.1016/j.cjca.2017.05.007Sefton EM, Gallardo M, Kardon G.Developmental origin and morphogenesis of the diaphragm, an essential mammalian muscle.Dev Biol. 2018;440(2):64-73. doi:10.1016/j.ydbio.2018.04.010Olugbade T, Bianchi-Berthouze N, Williams AC de C.The relationship between guarding, pain, and emotion.Pain Rep. 2019;4(4):e770. doi:10.1097/PR9.0000000000000770Armstrong RA.Visual problems associated with traumatic brain injury.Clin Exp Optom. 2018;101(6):716-726. doi:10.1111/cxo.12670Green-Hopkins I, Monuteaux MC, Lee LK, Nigrovic LE, Mannix R, Schutzman SA.Use of ondansetron for vomiting after head trauma: does it mask clinically significant traumatic brain injury?Pediatr Emerg Care. 2020;36(8):e433-e437. doi:10.1097/PEC.0000000000001315Wright WF.Cullen sign and grey turner sign revisited.J Am Osteopath Assoc. 2016;116(6):398-401. doi:10.7556/jaoa.2016.081National Institute of Neurological Disorders and Stroke.Traumatic brain injury (TBI).Kathuria H, Hollingsworth H, Vilvendhan R, Reardon C.Management of life-threatening hemoptysis.J Intensive Care. 2020 Apr;8(1):23. doi:10.1186/s40560-020-00441-8Cedars Sinai.Cardiac tamponade.Zaborski D, Halczak M, Grzesiak W, Modrzejewski A.Recording and analysis of bowel sounds.Euroasian J Hepatogastroenterol. 2016 Jul;5(2):67-73. doi:10.5005/jp-journals-10018-1137National Institute of Diabetes and Digestive and Kidney Diseases.Symptoms & causes of GI bleeding.Penn Medicine.Hematuria.NYU Langone Health.Diagnosing compartment syndrome.National Institute of Diabetes and Digestive and Kidney Issues.Diagnosis of GI Bleeding.Harntaweesup S, Krutsri C, Sumritpradit P, et al.Usefulness and outcome of whole-body computed tomography (Pan-scan) in trauma patients: A prospective study.Ann Med Surg (Lond). 2022;76:103506. doi:10.1016/j.amsu.2022.103506National Institute of Diabetes and Digestive and Kidney Diseases.Diagnosis of GI bleeding.Standl T, Annecke T, Cascorbi I, R. Heller A, Sabashnikov A, Teske W.The nomenclature, definition and distinction of types of shock.Dtsch Arztebl Int. 2018;115(45):757-768. doi:10.3238/arztebl.2018.0757Hooper N, Armstrong TJ.Hemorrhagic shock. In:StatPearls [Internet].Magid-Bernstein J, Girard R, Polster S, et al.Cerebral hemorrhage: pathophysiology, treatment, and future directions.Circ Res. 2022;130(8):1204-1229. doi:10.1161/CIRCRESAHA.121.319949Children’s Hospital of Philadelphia.Bleeding in pregnancy/placenta previa/placental abruption.Bumrungrad International Hospital.Vaginal bleeding in late pregnancy.CARE Hospitals.Internal bleeding: Signs, symptoms, causes & treatment.Maegele M.The diagnosis and treatment of acute traumatic bleeding and coagulopathy.Dtsch Arztebl Int. 2019 Nov;116(47):799–806. doi:10.3238/arztebl.2019.0799
Apollo Hospitals.Hemorrhage: Types, causes, symptoms, treatment, and more.
Latif R, Clifford S, Baker J, et al.Traumatic hemorrhage and chain of survival.Scand J Trauma Resusc Emerg Med. 2023;31(1):25. doi:10.1186/s13049-023-01088-8
Varma D, Brown P, Clements W.Importance of the mechanism of injury in trauma radiology decision-making.Korean Journal of Radiology. 2023;24(6):522. doi:10.3348/kjr.2022.0966
Mathur A, Mohan V, Ameta D, Gaurav B, Haranahalli P.Aortic aneurysm.J Transl Int Med. 2016;4(1):35-41. doi:10.1515/jtim-2016-0008
American Heart Association.Types of aneurysms.
National Heart, Lung & Blood Institute.What are bleeding disorders.
Tai FWD, McAlindon ME.Non-steroidal anti-inflammatory drugs and the gastrointestinal tract.Clin Med (Lond). 2021;21(2):131-134. doi:10.7861/clinmed.2021-0039
Fhogartaigh CN, Aarons E.Viral haemorrhagic fever.Clin Med (Lond).2015 Feb;15(1):61–6. doi:10.7861/clinmedicine.15-1-61
Arnold AC, Raj SR.Orthostatic hypotension: a practical approach to investigation and management.Can J Cardiol. 2017;33(12):1725-1728. doi:10.1016/j.cjca.2017.05.007
Sefton EM, Gallardo M, Kardon G.Developmental origin and morphogenesis of the diaphragm, an essential mammalian muscle.Dev Biol. 2018;440(2):64-73. doi:10.1016/j.ydbio.2018.04.010
Olugbade T, Bianchi-Berthouze N, Williams AC de C.The relationship between guarding, pain, and emotion.Pain Rep. 2019;4(4):e770. doi:10.1097/PR9.0000000000000770
Armstrong RA.Visual problems associated with traumatic brain injury.Clin Exp Optom. 2018;101(6):716-726. doi:10.1111/cxo.12670
Green-Hopkins I, Monuteaux MC, Lee LK, Nigrovic LE, Mannix R, Schutzman SA.Use of ondansetron for vomiting after head trauma: does it mask clinically significant traumatic brain injury?Pediatr Emerg Care. 2020;36(8):e433-e437. doi:10.1097/PEC.0000000000001315
Wright WF.Cullen sign and grey turner sign revisited.J Am Osteopath Assoc. 2016;116(6):398-401. doi:10.7556/jaoa.2016.081
National Institute of Neurological Disorders and Stroke.Traumatic brain injury (TBI).
Kathuria H, Hollingsworth H, Vilvendhan R, Reardon C.Management of life-threatening hemoptysis.J Intensive Care. 2020 Apr;8(1):23. doi:10.1186/s40560-020-00441-8
Cedars Sinai.Cardiac tamponade.
Zaborski D, Halczak M, Grzesiak W, Modrzejewski A.Recording and analysis of bowel sounds.Euroasian J Hepatogastroenterol. 2016 Jul;5(2):67-73. doi:10.5005/jp-journals-10018-1137
National Institute of Diabetes and Digestive and Kidney Diseases.Symptoms & causes of GI bleeding.
Penn Medicine.Hematuria.
NYU Langone Health.Diagnosing compartment syndrome.
National Institute of Diabetes and Digestive and Kidney Issues.Diagnosis of GI Bleeding.
Harntaweesup S, Krutsri C, Sumritpradit P, et al.Usefulness and outcome of whole-body computed tomography (Pan-scan) in trauma patients: A prospective study.Ann Med Surg (Lond). 2022;76:103506. doi:10.1016/j.amsu.2022.103506
National Institute of Diabetes and Digestive and Kidney Diseases.Diagnosis of GI bleeding.
Standl T, Annecke T, Cascorbi I, R. Heller A, Sabashnikov A, Teske W.The nomenclature, definition and distinction of types of shock.Dtsch Arztebl Int. 2018;115(45):757-768. doi:10.3238/arztebl.2018.0757
Hooper N, Armstrong TJ.Hemorrhagic shock. In:StatPearls [Internet].
Magid-Bernstein J, Girard R, Polster S, et al.Cerebral hemorrhage: pathophysiology, treatment, and future directions.Circ Res. 2022;130(8):1204-1229. doi:10.1161/CIRCRESAHA.121.319949
Children’s Hospital of Philadelphia.Bleeding in pregnancy/placenta previa/placental abruption.
Bumrungrad International Hospital.Vaginal bleeding in late pregnancy.
CARE Hospitals.Internal bleeding: Signs, symptoms, causes & treatment.
Maegele M.The diagnosis and treatment of acute traumatic bleeding and coagulopathy.Dtsch Arztebl Int. 2019 Nov;116(47):799–806. doi:10.3238/arztebl.2019.0799
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