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

Evaluation and Management of Spontaneous Bruising

The evaluation of spontaneous bruising requires a thorough assessment of bleeding history, physical examination findings, and targeted laboratory testing to distinguish between benign causes, bleeding disorders, and potential non-accidental trauma. 1

Initial Assessment

Key History Elements

• Bleeding history:
  • Timing and pattern of bruising (sudden onset vs. gradual)
  • Location of bruises (suspicious locations include buttocks, ears, genitals)
  • Presence of other bleeding symptoms (epistaxis, gum bleeding, heavy menstrual bleeding)
  • Previous excessive bleeding after surgery, dental procedures, or circumcision
  • Medication use (anticoagulants, NSAIDs, certain supplements)
  • Family history of bleeding disorders

Physical Examination Focus

• Distribution and pattern of bruises
  • Bruises in unusual locations (non-ambulatory surfaces) or patterned bruises raise concern for abuse
  • Bruises in typical locations (shins, knees, elbows) are often benign
• Presence of petechiae at clothing line pressure sites
• Signs of systemic disease (hepatomegaly, splenomegaly)
• Joint examination for evidence of hemarthrosis

Laboratory Evaluation

Initial Screening Tests

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

Interpretation of Initial Tests

• Normal PT and aPTT: Consider platelet disorders or von Willebrand disease
• Normal PT, prolonged aPTT: Suggests intrinsic pathway disorder (hemophilia A or B, factor XI deficiency)
• Prolonged PT, normal aPTT: Suggests extrinsic pathway disorder (factor VII deficiency)
• Both PT and aPTT prolonged: Consider liver disease, vitamin K deficiency, DIC, or multiple factor deficiencies

Diagnostic Algorithm

When to Pursue Further Testing

Further laboratory evaluation is indicated when:

• History reveals excessive bleeding with minor trauma
• Family history of bleeding disorder
• Physical examination shows mucocutaneous bleeding or hemarthroses
• Initial screening tests are abnormal

When Testing Can Be Limited

Laboratory evaluation may not be necessary when:

• Bruising is in typical locations for accidental trauma
• There is a clear history of trauma that explains the bruising
• The patient has patterned bruising consistent with an object
• The patient or witness provides a history of trauma that explains the bruising

Management Approach

For Normal Laboratory Results with Concerning History

• Consider von Willebrand disease testing (not detected by routine PT/aPTT)
• Evaluate for platelet function disorders with specialized testing
• Hematology consultation if suspicion remains high despite normal initial tests

For Abnormal Laboratory Results

• Prolonged PT: Vitamin K challenge test if nutritional deficiency suspected
• Prolonged aPTT: Perform mixing study to distinguish factor deficiency from inhibitor
• Thrombocytopenia: Evaluate for immune thrombocytopenia, drug effects, or bone marrow disorders

For Suspected Child Abuse

• Document bruising pattern and location carefully
• Consider child abuse pediatrician consultation in complex cases
• Remember that the presence of a bleeding disorder does not exclude the possibility of abuse

Special Considerations

Vitamin K Deficiency

• Consider in infants with bruising, especially if vitamin K was not administered at birth
• Presents with prolonged PT and possibly prolonged aPTT
• May cause skin bleeding, mucosal bleeding, or intracranial hemorrhage

Immune Thrombocytopenia (ITP)

• Transient, often self-resolving bleeding disorder
• Presents with isolated thrombocytopenia with normal PT/aPTT
• May require follow-up evaluation after change in home setting to distinguish from abuse

Common Pitfalls to Avoid

1. Failing to consider non-accidental trauma in vulnerable populations
2. Overlooking medication effects on coagulation
3. Assuming normal PT and aPTT rule out all bleeding disorders
4. Inadequate evaluation of family history
5. Inappropriate handling of coagulation test specimens leading to false-positive results

Remember that bleeding disorders are generally permanent conditions that do not resolve with a change in caregivers, with the exception of ITP, which can be transient 1. When initial evaluation suggests a bleeding disorder or when suspicion remains high despite normal laboratory results, consultation with a hematologist is recommended 2.