From the Guidelines
The initial evaluation and management of epistaxis with a suspected systemic cause requires a comprehensive approach, starting with stabilization of the patient and identification of potential systemic causes, including coagulopathies, hypertension, liver disease, or medication effects, as outlined in the clinical practice guideline by 1 and 1. The differential diagnosis for systemic causes of epistaxis includes:
- Coagulopathies, such as those caused by anticoagulant or antiplatelet medications
- Hypertension
- Liver disease
- Bleeding disorders, such as hemophilia or von Willebrand disease
- Renal disease
- Malignancy
To evaluate these potential causes, the following workup is recommended:
- Complete blood count
- Coagulation studies, including PT/INR and PTT
- Type and screen if significant blood loss is suspected
- Liver function tests if liver disease is suspected
- Renal function tests if renal disease is suspected
- Imaging studies, such as CT or MRI, if a tumor or other structural abnormality is suspected
The first step in managing epistaxis in patients on anticoagulation or antiplatelet medications is to use "first-line" treatments, including nasal compression, vasoconstrictors, moisturizing or lubricating agents, nasal cautery, and/or nasal packing, as recommended by 1. If these measures fail to control the bleeding, reversal strategies may be considered, such as:
- Fresh frozen plasma (10-15 mL/kg) for vitamin K antagonist reversal
- Prothrombin complex concentrate (25-50 units/kg) for urgent reversal
- Platelet transfusion (1 unit per 10 kg body weight) for thrombocytopenia or platelet dysfunction
- Vitamin K (5-10 mg IV or oral) for warfarin reversal
- Temporary discontinuation of anticoagulant medication in consultation with the prescribing physician, weighing bleeding risk against thrombotic risk, as discussed in 1.
From the Research
Differential Diagnosis for Systemic Cause of Epistaxis
The differential diagnosis for systemic causes of epistaxis includes:
- Bleeding disorders such as hemophilia or von Willebrand disease 2, 3
- Coagulopathies, including those caused by anticoagulant medication or chronic liver disease 4, 3
- Neoplasia, such as nasal or sinus tumors 2
- Hypertension, which can increase the risk of epistaxis 4, 5
- Inherited bleeding diatheses, such as thrombocytopenia or platelet function disorders 2, 5
Workup for Systemic Causes of Epistaxis
The workup for systemic causes of epistaxis may include:
- Focused history taking to identify underlying medical conditions or medications that may be contributing to the epistaxis 4
- Clinical examination to assess for signs of bleeding disorders or other systemic conditions 4
- Coagulation studies, such as prothrombin time and activated partial thromboplastin time, in patients with a history of anticoagulant use or bleeding diatheses 4, 3
- Laboratory tests to evaluate for underlying conditions such as anemia or thrombocytopenia 5
- Imaging studies, such as CT or MRI, to evaluate for nasal or sinus tumors or other structural abnormalities 5