Bruising and Bleeding

INTRODUCTION

Many patients present with the complaint that they bruise easily but only a minority turn out to have an underlying blood disorder.

Key facts and checkpoints

• Purpura = petechiae ± ecchymoses

• Abnormal bleeding is basically the result of disorders of (1) the platelet, (2) the coagulation mechanism or (3) the blood vessel

• There is no substitute for a good history in the assessment of patients with bleeding disorders

• An assessment of the personal and family histories is the first step in the identification of a bleeding disorder

• When a patient complains of ‘bruising easily’ it is important to exclude thrombocytopenia due to bone marrow disease and clotting factor deficiencies such as haemophilia

• Differential diagnosis: ‘Palpable purpura’ due to an underlying systemic vasculitis is an important differential problem. The petechiae are raised so finger palpation is important. The cause is an underlying vasculitis affecting small vessels (e.g. polyarteritis nodosa).

PURPURA

• In general, bleeding secondary to platelet defects is spontaneous, associated with a petechial rash and occurs immediately after trauma or a cut wound

• Laboratory assessment should be guided by the clinical impression

• Bleeding caused by coagulation factor deficiency is usu. traumatic and delayed (e.g. haemorrhage occurring 24 h after a dental extraction in a haemophiliac)

• The routine screening tests for the investigation of patients with bleeding disorders can be normal despite the presence of a severe haemorrhagic state

Investigations Apart from the basic tests of FBE and film, ferritin, LFTs and U&Es, the initial choice of investigations depends upon the bleeding pattern.

If coagulation defect suspected:

• prothrombin time (PT), i.e. INR

• activated partial thromboplastin time (APTT)

• fibrinogen level

• thrombin time (TT)

If platelet pathology suspected:

• platelet count

• platelet function analyser (PFA-100)

If inherited disorders suspected:

• factor VIII (haemophilia A)

• von Willebrand factor activity

• von Willebrand factor antigen

The FBE and blood film is useful in pinpointing the aetiology. Other special tests such as von Willebrand screen and PFA-100 can be advised by the consultant. The bone marrow examination is useful to exclude the secondary causes of thrombocytopenia, such as leukaemia, other marrow infiltrations ...