What is the evaluation and management approach for spontaneous bruising?

Evaluation and Management of Spontaneous Bruising

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

Initial Assessment

History Elements to Focus On:

• Pattern and location of bruising
• Timing and triggers of bruising episodes
• Family history of bleeding disorders
• Medication use (anticoagulants, NSAIDs, supplements)
• Bleeding with procedures or surgeries
• Menstrual bleeding pattern in females
• History of epistaxis or gum bleeding

Physical Examination:

• Document size, location, and appearance of bruises
• Assess for other signs of bleeding (petechiae, purpura)
• Look for signs of systemic disease
• Consider photographing unusual bruising patterns

Laboratory Evaluation Algorithm

First-Line Testing:

• Complete blood count with platelet count
• Peripheral blood smear
• Prothrombin time (PT)
• Activated partial thromboplastin time (aPTT)
• Fibrinogen level 1, 2

Interpretation of Results:

• Normal PT and aPTT: Consider platelet disorders or von Willebrand disease
• Prolonged PT, normal aPTT: Suspect extrinsic pathway disorder (e.g., factor VII deficiency)
• Normal PT, prolonged aPTT: Suspect intrinsic pathway disorder (e.g., hemophilia A or B)
• Both PT and aPTT prolonged: Consider liver disease, vitamin K deficiency, DIC, or multiple factor deficiencies 1

Specialized Testing

• Von Willebrand disease testing (not detected by routine PT/aPTT)
• Platelet function tests
• Factor assays based on initial testing results
• Consider hematology consultation if suspicion remains high despite normal initial tests 1, 2

Special Considerations

Pediatric Patients:

• Always consider non-accidental trauma, especially in vulnerable populations 1, 3
• Evaluate for vitamin K deficiency in infants, especially if vitamin K was not administered at birth 1
• Transient bleeding disorders may occur in children without common bleeding disorders 4

Rare Conditions:

• Consider Achenbach syndrome in cases of spontaneous, recurrent bruising of digits without evidence of systemic disease 5
• Be aware of transient acquired inhibitors of coagulation that can cause spontaneous bleeding 6

Management Approach

1. Treat underlying cause if identified
2. Hematology consultation for confirmed bleeding disorders
3. Consider child abuse pediatrician consultation in complex pediatric cases 1
4. Reassurance for benign conditions like Achenbach syndrome to prevent unnecessary invasive workup 5

Common Pitfalls to Avoid

• Failing to consider non-accidental trauma in vulnerable populations
• Overlooking medication effects on coagulation
• Assuming normal PT and aPTT rule out all bleeding disorders (they don't detect von Willebrand disease or platelet function disorders)
• Excessive testing without systematic approach
• Missing family history of bleeding disorders 1, 2

Using bleeding assessment tools and patient-provided photographs can help document and track bruising patterns over time, aiding in diagnosis 2.