What is the workup for a patient who bruises easily?

Workup for Easy Bruising

The initial workup for a patient who bruises easily should include a complete blood count, peripheral blood smear, prothrombin time (PT), and activated partial thromboplastin time (aPTT) to screen for common bleeding disorders. 1

Initial Assessment

History

• Bleeding symptoms to document:
  • Significant bleeding after surgery, dental procedures, or circumcision
  • Epistaxis (nosebleeds)
  • Bleeding from umbilical stump
  • Mucocutaneous bleeding
  • Family history of bleeding disorders
  • Ethnicity associated with higher rates of bleeding disorders 2
  • Medication use (anticoagulants, NSAIDs, certain supplements)

Physical Examination

• Key areas to examine:
  • Pattern and distribution of bruising
  • Presence of bruising in locations suspicious for abuse (buttocks, ears, genitals)
  • Mucocutaneous bleeding (suggests platelet dysfunction)
  • Joint bleeding/hemarthroses (suggests coagulopathy)

Laboratory Evaluation Algorithm

First-Line Tests

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

Interpretation and Next Steps

If PT and aPTT are normal:

• Consider platelet disorder or von Willebrand disease (VWD)
  • VWD is the most common inherited bleeding disorder 3
  • Proceed with VWD testing:
    • VWF antigen
    • VWF activity
    • Factor VIII coagulant activity
    • VWF:RCo/VWF:Ag ratio 4

If PT is normal but aPTT is prolonged:

• Indicates a deficit in the intrinsic pathway
  • Perform mixing study to differentiate between factor deficiency and inhibitor 1
  • Consider hemophilia A or B

If PT is prolonged but aPTT is normal:

• Indicates a deficit in the extrinsic pathway
  • Consider vitamin K deficiency
  • Perform vitamin K challenge test 3

If both PT and aPTT are prolonged:

• Consider liver disease, DIC, or multiple factor deficiencies
  • Add fibrinogen testing
  • Evaluate for liver failure 3

Special Considerations

When to Consider Specialized Testing

• Strong bleeding history but normal initial tests:
  • Consider specialized VWD studies such as multimer analysis
  • Consider genetic testing
  • Use standardized bleeding assessment tool (BAT) 4
  • May need to repeat testing up to 3 times (VWF levels can vary) 4

When to Consider Non-Hematologic Causes

• Other medical conditions that can cause easy bruising:
  • Ehlers-Danlos syndrome
  • Scurvy
  • Cancer and infiltrative disorders
  • Glutaric aciduria
  • Arteriovenous malformations 2

When to Refer to a Hematologist

• Initial testing indicates a bleeding disorder
• High clinical suspicion despite normal laboratory workup
• Strong family history of bleeding disorders 1

Common Pitfalls to Avoid

1. Overlooking medication effects - Document all medications as certain drugs can affect test results, particularly platelet function tests 2

2. Indiscriminate testing - Avoid performing extensive laboratory testing in every patient; target testing based on history and physical exam findings 2

3. Single testing only - VWF levels can vary, and testing may need to be repeated up to 3 times for reliable results 4

4. Missing mild disorders - Initial VWD testing can be normal even in patients with type 2 variants, requiring specialized studies 4

5. Ignoring non-hematologic causes - Consider conditions like Ehlers-Danlos syndrome or scurvy when appropriate 2

By following this systematic approach, clinicians can efficiently identify the cause of easy bruising and determine appropriate management or referral pathways.