II. Epidemiology
- Bleeding Gums, Epistaxis and easy bruisability are common in healthy patients (occurs in up to 45%)
-
Menorrhagia is very common in women (5-10%)
- Bleeding Disorders contribute to up to 29% of Menorrhagia cases (esp. Von Willebrand Disorder)
III. History: Symptoms or clinical clues
- Critical Illness or hospitalization
- Acute Diarrhea (E. coli 0157:H7)
- Upper Respiratory Infection (esp. Streptococcal Pharyngitis)
- Chronic Bleeding Disorder
- Systemic Lupus Erythematosus
- Ehlers-Danlos Syndrome
- Hypermobile joints
- Von Willebrand Disease
- Menorrhagia (most common), recurrent Epistaxis or Gingival Bleeding
- Often delayed diagnosis with normal basic coagulation labs (until platelet closure time is checked)
- Hemophilia A (Factor VIII) or Hemophilia B (Factor IX) deficiency
- Hemoarthrosis or other soft tissue bleeding in males
- Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu Syndrome)
- Telangiectasias involving lips, Tongue, skin, nose and GI tract
- Immune Thrombocytopenic Purpura
- Especially children (often following viral syndrome such as EBV, VZV or CMV)
-
Night Sweats and weight loss
- Hematologic Malignancy (Leukemia, Myelodyspastic syndrome, Lymphoma)
- Malnutrition
-
Bruising
- Physical Abuse
-
Purpura Simplex
- Women with Bruising on arms and upper thighs
-
Senile Purpura
- Older adults with dark Bruises in areas of thin skin (esp. extensor arms)
- Pregnancy
- HELLP Syndrome
- Severe Preeclampsia with Hemolysis, elevated liver enzymes and Low Platelet Count
- HELLP Syndrome
IV. History
- Screening Questions for congenital Bleeding Disorder
-
Family History of Bleeding Disorder (e.g. Hemophilia, Von Willebrand Disease)
- Include second-degree relatives, and back several generations
- Negative Family History does not exclude inherited Bleeding Disorder
- Medications
V. Signs: Abnormal Bleeding (multiple sites)
- Nasopharynx
- Gastrointestinal
- Hematemesis
- Melana
- Gynecologic
- Musculoskeletal
- Muscle hematomas
- Hemarthrosis
- Skin
-
Trauma
- Excessive bleeding from minor wounds
- Excessive bleeding following surgery or dental procedures
- Intracerebral bleeding event
VI. Signs: Clinical Clues
- Spontaneous hemarthrosis, muscle Hemorrhage or retroperitoneal bleeding
- Congenital Bleeding Disorder
- Mucocutaneous bleeding (Petechiae, Epistaxis, Gingival Bleeding, GI Bleeding, GU Bleeding)
-
Hepatomegaly
- Liver disorder
- Splenomegaly
VII. Causes
- Coagulation Disorder
- Platelet Disorders
- Vascular Disorders
- See Blood Vessel Wall Bleeding Disorders
VIII. Labs: Initial
- Complete Blood Count with platelets
- Peripheral Blood Smear
- ProTime (PT) with INR
- Partial Thromboplastin Time (PTT)
- Comprehensive metabolic panel (Liver Function Tests and Renal Function tests)
IX. Labs: Based on initial testing
- Normal PT, PTT, and Platelet Count/morphology
- Obtain labs
- Von Willebrand Factor Antigen
- Von Willebrand Factor Activity (risocetin Cofactor activity)
- Factor VIII Level
- AVOID Platelet Function Closure Time (PFCT, Platelet Function Analyzer-100)
- No longer recommended due to False Negatives in less than severe cases of Von Willebrand
- Abnormal labs
- Von Willebrand Disease (additional testing can identify type)
- Normal labs
- Refer to hematology for additional evaluation of platelet function disorder
- May require light transmission aggregometry
- Obtain labs
- Partial Thromboblastin Time (PTT) abnormality and Normal PT/INR (Intrinsic Clotting Pathway Abnormal)
- PTT corrects with a PTT Mixing Study (patient plasma mixed 1:1 with normal plasma)
- Obtain Factor VIII, Factor IX, and Factor XI assays
- Consider Von Willebrand's testing if low Factor VIII
- PTT does not correct with a PTT Mixing Study (mixed with normal blood)
- Obtain Lupus Anticoagulant
- Obtain Factor VIII Inhibitor
- PTT corrects with a PTT Mixing Study (patient plasma mixed 1:1 with normal plasma)
-
ProTime (PT) or INR abnormal and Normal PTT (Extrinsic Clotting Pathway Abnormal) - uncommon
- PT/INR corrects with Vitamin K Supplementation
- Replace Vitamin K as needed
- Assess for Malnutrition and malabsorption causes of Vitamin K Deficiency
- PT/INR does not correct with Vitamin K Supplementation
- Obtain Factor VII assay
- PT/INR corrects with Vitamin K Supplementation
- BOTH ProTime (PT/INR) and Partial Thromboplastin Time (PTT) Abnormal
- Causes
- Comorbid advanced liver disease
- Disseminated Intravascular Coagulation (DIC)
- Anticoagulant use (Warfarin or Heparin)
- Combined Intrinsic Clotting Pathway and Extrinsic Clotting Pathway
- Labs
- Liver Function Tests
- Fibrinogen level
- Factor Assays
- Causes
- Platelet abnormality
X. Management: Hematology Consultation indications
- Significant finding on testing
- Nondiagnostic results with high clinical suspicion
- Preoperative concern for Bleeding Disorder
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Definition (MEDLINEPLUS) |
Normally, if you get hurt, your body forms a blood clot to stop the bleeding. For blood to clot, your body needs cells called platelets and proteins known as clotting factors. If you have a bleeding disorder, you either do not have enough platelets or clotting factors or they don't work the way they should. Bleeding disorders can be the result of other diseases, such as severe liver disease. They can also be inherited. Hemophilia is an inherited bleeding disorder. Bleeding disorders can also be a side effect of medicines. |
Concepts | Pathologic Function (T046) |
SnomedCT | 123329004, 78596001, 267562007, 64779008, 248250000 |
Italian | Predisposizioni al sanguinamento, Predisposizione al sanguinamento |
Dutch | bloedingsneiging, diathese; hemorrhagie, hemorrhagie; diathese, bloedingsneigingen |
French | Syndrome hémorragique, Syndromes hémorragiques |
German | Blutungsneigung, Blutungsneigungen |
Portuguese | Tendência hemorrágica, Tendências hemorrágicas |
Spanish | Diátesis hemorrágica, diátesis hemorrágica - RETIRADO - (concepto no activo), diátesis hemorrágica - RETIRADO -, diátesis hemorrágica, trastorno hemorrágico, tendencia hemorrágica, diátesis hemorrágica (concepto no activo), tendencia al sangrado (entidad observable), tendencia al sangrado, Diátesis hemorrágicas |
Japanese | 出血傾向, シュッケツケイコウ |
Czech | Krvácivé stavy, Krvácivý stav |
English | Bleeding tendencies, Bleeding Disorders, Bleeding diathesis (disorder), Bleeding disorders, Bleeding diathesis, Bleeding disorder, Tendency to bleed, Tendency to bleed (observable entity), bleeding tendency, bleeding; diathesis, diathesis; bleeding, Bleeding diathesis -RETIRED-, Bleeding tendency, Disability due to bleed disord, bleeding disorder |
Hungarian | Vérzéshajlamok, vérzéses tendencia |