What causes bruising in adults and how is it managed?

Causes and Management of Bruising in Adults

The most common causes of bruising in adults are trauma, medication effects (especially anticoagulants), and underlying bleeding disorders, with management focused on treating the underlying cause and preventing complications that could lead to serious morbidity or mortality.

Common Causes of Bruising

Traumatic Causes

• Direct trauma or injury
• Accidental injuries
• Surgical procedures
• Falls (especially in elderly)

Medication-Related Causes

• Anticoagulants (warfarin, direct oral anticoagulants)
• Antiplatelet medications (aspirin, clopidogrel)
• SSRIs (like fluoxetine) which can affect platelet function 1
• NSAIDs which impair platelet function

Bleeding Disorders

1. Platelet disorders:

   • Thrombocytopenia
   • Platelet function disorders
   • Immune thrombocytopenia (ITP) 2
   • Von Willebrand disease (most common inherited bleeding disorder)

2. Coagulation disorders:

   • Hemophilia
   • Factor deficiencies
   • Vitamin K deficiency

3. Vascular disorders:

   • Easy bruising syndrome 3
   • Connective tissue disorders
   • Senile purpura (in elderly)

Diagnostic Approach

Initial Assessment

1. Bleeding history assessment:

   • Use a standardized bleeding assessment tool (BAT) 2
   • Document pattern, frequency, and severity of bruising
   • Determine if bruising is disproportionate to trauma
   • Identify family history of bleeding disorders 4

2. Medication review:

   • Identify medications that affect hemostasis
   • Check for anticoagulant use (warfarin can cause serious bleeding) 5
   • Review herbal supplements and OTC medications

3. Physical examination:

   • Distribution and characteristics of bruises
   • Mucocutaneous bleeding suggests platelet dysfunction
   • Hemarthroses or deep hematomas suggest coagulopathy
   • Check for signs of systemic disease

Laboratory Testing

1. First-line tests 4:

   • Complete blood count (CBC) with platelet count
   • Peripheral blood smear
   • Prothrombin time (PT)/International Normalized Ratio (INR)
   • Activated partial thromboplastin time (aPTT)
   • Fibrinogen level

2. Interpretation of results:

   • Normal PT and aPTT with abnormal bleeding → consider platelet disorder
   • Normal PT with prolonged aPTT → intrinsic pathway disorder
   • Prolonged PT with normal aPTT → extrinsic pathway disorder
   • Both PT and aPTT prolonged → consider liver disease or multiple factor deficiencies

3. Additional testing based on initial results:

   • Von Willebrand factor testing
   • Platelet function studies
   • Specific factor assays
   • Mixing studies for factor inhibitors

Management Strategies

General Principles

1. Treat the underlying cause:

   • Adjust or discontinue medications causing bleeding
   • Treat specific bleeding disorders
   • Address traumatic causes

2. Acute bleeding management:

   • Direct pressure for superficial bleeding
   • Cold compresses to reduce bruising
   • Elevation of affected limb if applicable

Specific Treatments

1. For medication-induced bruising:

   • Dose adjustment or medication change
   • For warfarin: monitor INR regularly and maintain in therapeutic range 5
   • Consider antidotes if severe bleeding (vitamin K for warfarin)

2. For platelet disorders:

   • Tranexamic acid (TXA) for minor bleeding 2
   • Desmopressin (DDAVP) for certain platelet disorders 2
   • Platelet transfusions for severe thrombocytopenia or bleeding

3. For coagulation factor deficiencies:

   • Factor replacement therapy
   • Fresh frozen plasma
   • Prothrombin complex concentrates
   • Fibrinogen concentrate for fibrinogen deficiency 2

4. For trauma-related bruising:

   • RICE (Rest, Ice, Compression, Elevation)
   • Pain management
   • For major trauma: follow damage control principles 2

Special Considerations

1. Elderly patients:

   • More susceptible to bruising due to skin fragility
   • Higher risk of medication interactions
   • Consider fall prevention strategies

2. Patients on anticoagulants:

   • Regular monitoring of anticoagulation levels
   • Education about bleeding risks
   • Identification card indicating anticoagulant use 5

3. Bleeding disorders of unknown cause (BDUC):

   • TXA is first-line treatment for minor procedures 2
   • Combined approach with DDAVP for major procedures
   • Hematology consultation for persistent unexplained bruising

When to Refer to Hematology

• Abnormal laboratory results suggesting bleeding disorder
• Family history of bleeding disorders
• Recurrent or severe bruising without clear cause
• Bruising accompanied by other bleeding symptoms
• High clinical suspicion despite normal initial testing 4

Prevention Strategies

• Medication review and adjustment to minimize bleeding risk
• Fall prevention in elderly
• Protective equipment during activities with high risk of trauma
• Patient education about bruising risks and when to seek medical attention
• Regular monitoring for patients on anticoagulants

Common Pitfalls to Avoid

• Dismissing bruising as minor without adequate evaluation
• Failing to consider medication effects on bleeding
• Not obtaining family history of bleeding disorders
• Overlooking the possibility of abuse in vulnerable populations
• Inadequate follow-up of abnormal laboratory results

Remember that easy bruising may be the first sign of a serious underlying condition, and thorough evaluation is essential for proper diagnosis and management.