Excessive Bleeding or Clotting (Case 28)

Published on 24/06/2015 by admin

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Last modified 24/06/2015

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Excessive Bleeding or Clotting (Case 28)

Rebecca Kruse-Jarres MD, MPH

Case: A 74-year-old woman is in good general health except for hypothyroidism, which is well controlled on thyroid hormone replacement. Over the past month she noticed that she started bruising easily. She had never before had a problem with easy bruising, prolonged bleeding from cuts, or other unusual bleeding. She goes to see her primary-care physician, who orders a bleeding time. She presents to the ED 5 days after the test because she is still bleeding from the test site. She has multiple bruises covering her arms, trunk, and legs.

Differential Diagnosis

Immune thrombocytopenic purpura (ITP)

DIC

Acquired factor VIII deficiency

Drug-induced thrombocytopenia

Vitamin K deficiency

Thrombotic thrombocytopenic purpura (TTP)

 

Speaking Intelligently

When I encounter a patient with bleeding, the most important approach is to take a detailed history and perform a physical examination. First, I like to establish whether the bleeding disorder is of a chronic nature. Is this a condition the patient had all of his or her life, and do I have to think about congenital causes (such as hemophilia or von Willebrand’s disease), or is this of recent onset and more likely an “acquired” condition?

If the problem seems to have been going on for a significant portion of the patient’s life, it is crucial to get a good family history of any family member with bleeding tendencies and to draw a pedigree to establish the inheritance pattern.

If the bleeding is of more recent onset, it is critical to elicit any changes in the patient’s life that may have been contributory, such as new medications, newly diagnosed other medical conditions, other associated symptoms, and recent travel.

Finally, it is important to separate disorders of primary hemostasis from disorders of secondary hemostasis. Patients with primary hemostatic disorders usually present with superficial bleeding such as easy bruisability, gum bleeding, or menorrhagia; the primary hemostatic system involves platelets, von Willebrand factor, and a vessel wall. Patients with disorders of secondary hemostasis, such as factor deficiencies, usually present with deep bleeding such as cerebral hemorrhage or bleeding into muscles and joints.

PATIENT CARE

Clinical Thinking

• This patient seems to have an acquired problem that started causing symptoms (i.e., bruising) about 1 month before her presentation.

• She also appears to have a disorder of primary hemostasis.

• It is important to investigate any possible triggers for the new symptoms such as recent medication changes or travel.

• The physical exam may point to other possible etiologies, such as a hematologic malignancy, which can cause thrombocytopenia.

History

• In investigating a bleeding disorder, it is essential to differentiate a congenital from an acquired condition.

• Once an acquired condition is suspected, it is crucial to elicit the severity, duration, speed of progression, and associated circumstances. Examples include changes in the patient’s health such as new medical diagnoses, newly prescribed medications, and recent surgeries.

• The patient’s past medical history is also important; patients with autoimmune disorders, such as thyroid disease or diabetes mellitus, may develop other autoimmune phenomena, such as ITP.

• DIC may accompany disorders such as malignancy or sepsis.

• Medications can also contribute to bleeding problems. For example, if the patient is on warfarin, change in certain other medications or diet could easily increase warfarin concentrations. Changes in diet or recent use of antibiotics can lead to vitamin K deficiency, causing bleeding and bruising.

• Patients with platelet disorders and von Willebrand disease, which are disorders of primary hemostasis, present with mucosal bleeding such as petechiae, mouth bleeding, and heavy menstrual bleeding. Factor deficiencies may lead to soft-tissue bleeding and bleeding from surgical sites.

• Especially in the elderly, a history of bruising has to raise a suspicion for potential physical abuse.

Physical Examination

• Determine the pattern and location of blood loss.

• Look for bruising, petechiae, and bleeding from cuts, surgical sites, and IV access sites.

• Evaluate for possible oropharyngeal, GI, and genitourinary bleeding.

• Remember to assess for the possibility of internal bleeding, such as intracranial hemorrhage, especially if the patient has symptoms or signs of neurologic abnormalities.

• Assess the mouth for signs of “wet” purpura characterized by blood-filled blisters.

Tests for Consideration

CBC: To determine the platelet count and see whether other cell lines (WBCs, RBCs) are normal or abnormal.

$11

Hemoglobin/hematocrit: May help in estimating how much bleeding has occurred, if a baseline is available.

$7

Peripheral smear is essential in almost every hematologic disorder.

$5

• There could be platelet clumping, ruling out a true thrombocytopenia.

• Blast cells are worrisome for an acute leukemia.

• Schistocytes could be indicative of the microangiopathic hemolytic anemia of DIC or TTP.

• ITP results in a normal smear except for thrombocytopenia.

 

Prothrombin time (PT): Assesses the extrinsic and common coagulation pathway (factors II, V, VII, X, and fibrinogen).

$6

Activated partial thromboplastin time (aPTT):
Assesses the intrinsic and common coagulation pathway (factor II, V, X, VIII, XI, XII, and fibrinogen).

$9

PT or aPTT mixing study: Prolongation of either can help to differentiate a factor deficiency from an inhibitor.

$6, $9

PFA-100 (has now replaced bleeding time in most places):
Screens for a platelet disorder but is not reliable in patients with thrombocytopenia.

$5

Fibrin degradation products (FDPs) or D-dimer:
Are elevated in DIC.

$14

Bone marrow aspirate and biopsy:

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