What is the evaluation and management approach for a patient with excessive bruising?

Evaluation and Management of Excessive Bruising

A thorough evaluation for excessive bruising should include a detailed medical history, physical examination, and targeted laboratory testing to identify underlying bleeding disorders, with initial screening tests including complete blood count, peripheral blood smear, prothrombin time (PT), and activated partial thromboplastin time (aPTT). 1

Initial Assessment

Key History Elements

• Timing and pattern of bruising
• Relationship to trauma or lack thereof
• Medication use (including anticoagulants, NSAIDs, supplements)
• Family history of bleeding disorders
• History of excessive bleeding after procedures (dental work, surgery, circumcision)
• Menstrual history in females (heavy bleeding)
• Presence of other bleeding symptoms (epistaxis, gum bleeding, hematuria)

Physical Examination Focus Points

• Distribution and pattern of bruises
• Presence of petechiae or purpura
• Mucosal bleeding
• Joint swelling or evidence of hemarthrosis
• Signs of systemic disease

Laboratory Evaluation Algorithm

First-line Testing

1. Complete blood count (CBC) with platelet count
2. Peripheral blood smear
3. Prothrombin time (PT)/International Normalized Ratio (INR)
4. Activated partial thromboplastin time (aPTT)
5. Fibrinogen level

Interpretation and Further Testing

• Normal PT and aPTT: Consider platelet dysfunction or von Willebrand disease (most common bleeding disorder) 2

  • Add von Willebrand factor antigen, ristocetin cofactor activity, factor VIII level
  • Consider platelet function testing

• Normal PT, prolonged aPTT: Indicates intrinsic pathway defect 1

  • Perform mixing study to differentiate factor deficiency from inhibitor
  • Test for specific factor deficiencies (VIII, IX, XI, XII)

• Prolonged PT, normal aPTT: Suggests extrinsic pathway disorder 1

  • Consider vitamin K deficiency
  • Test factor VII level

• Both PT and aPTT prolonged: Consider liver disease, vitamin K deficiency, DIC, or multiple factor deficiencies 2

Special Considerations

Child Abuse Evaluation

When evaluating bruising in children, particularly non-mobile infants:

• Bruising in non-mobile infants is highly suspicious for abuse 3
• Consider the pattern and location of bruises (bruises on buttocks, ears, and genitals have higher specificity for abuse) 4
• Laboratory evaluation for bleeding disorders should be conducted when abuse is suspected 4
• A patterned slap mark with consistent history does not require bleeding disorder evaluation 4

Common Pitfalls to Avoid

1. Inadequate history: Failure to ask about specific bleeding symptoms beyond bruising

   • Solution: Use a structured bleeding assessment tool like the one developed by the International Society on Thrombosis and Hemostasis 2

2. Premature conclusion: Assuming bruising is normal without adequate evaluation

   • Solution: Maintain high index of suspicion, especially with:
     • Bruising in unusual locations
     • Bruising without remembered trauma
     • Family history of bleeding

3. Specimen handling errors: Coagulation tests are sensitive to improper collection and handling

   • Solution: Ensure proper collection techniques and processing by experienced laboratories 4

4. Missing mild factor deficiencies: Some mild deficiencies may not cause abnormalities in screening tests

   • Solution: Consider specialized testing when clinical suspicion is high despite normal screening tests 1

Management Approach

For Normal Evaluation Results

• Reassurance if workup is negative and bruising pattern is consistent with normal variation
• Consider contributing factors:
  • Aging skin
  • Sun damage
  • Steroid use (topical or systemic)
  • Nutritional deficiencies

For Abnormal Results

• Management based on specific diagnosis:
  • Von Willebrand disease: Desmopressin, von Willebrand factor concentrates
  • Hemophilia: Factor replacement therapy
  • Platelet disorders: Platelet transfusions, antifibrinolytics
  • Vitamin K deficiency: Vitamin K supplementation

When to Refer to Hematology

• Abnormal laboratory findings
• Strong family history despite normal initial testing
• Recurrent or severe bleeding episodes
• High clinical suspicion despite normal initial laboratory workup 1

Follow-up

• Schedule follow-up based on severity and underlying diagnosis
• Monitor response to any implemented treatments
• Consider periodic reassessment of bleeding risk before procedures

Remember that while most cases of easy bruising are benign, a systematic approach to evaluation helps identify the minority of patients with significant underlying disorders that require specific management.