What is the approach to managing a patient with easy bruising?

Approach to Managing Easy Bruising

Begin by obtaining a detailed bleeding history using a validated bleeding assessment tool, then perform targeted laboratory testing starting with CBC, peripheral smear, PT, and aPTT to systematically identify or exclude underlying bleeding disorders. 1, 2

Initial Clinical Assessment

Structured Bleeding History

• Use the International Society on Thrombosis and Hemostasis bleeding assessment tool to systematically evaluate whether bruising represents true pathology versus normal variation 1
• Document specific bleeding manifestations:
  • Mucocutaneous bleeding (epistaxis, gum bleeding, menorrhagia, petechiae) suggests platelet dysfunction 1
  • Deep tissue bleeding (hemarthroses, muscle hematomas) indicates coagulopathy 1
  • Frequency, severity, and triggers of bruising episodes 2

Critical History Elements

• Family history of bleeding disorders is essential, particularly in children who may not have experienced major hemostatic challenges (surgery, trauma, dental extractions) 1, 2
• Complete medication review focusing on:
  • Anticoagulants (warfarin, DOACs) 3
  • Antiplatelet agents (aspirin, clopidogrel, NSAIDs) 3
  • Drugs increasing hyponatremia risk that may affect hemostasis 4
  • Divalproex sodium (requires platelet monitoring every 6 months) 3
• Screen for nonaccidental trauma, especially in vulnerable populations (children, elderly, dependent adults) 2

Physical Examination Findings

• Pattern of bruising:
  • Scattered petechiae on lower extremities suggest thrombocytopenia or platelet dysfunction 3
  • Large ecchymoses in unusual locations may indicate coagulopathy or trauma 1
  • Subcutaneous bleeding, muscle hematomas suggest acquired hemophilia A 3
• Associated findings:
  • Skin hyperextensibility, joint hypermobility, atrophic scarring suggest Ehlers-Danlos syndrome 5
  • Hepatosplenomegaly, lymphadenopathy suggest hematologic malignancy 3

Laboratory Evaluation Algorithm

First-Line Testing

Order these tests for all patients with concerning bleeding history: 1, 2

1. Complete blood count with platelet count
2. Peripheral blood smear (evaluate platelet morphology, rule out pseudothrombocytopenia)
3. Prothrombin time (PT) and INR
4. Activated partial thromboplastin time (aPTT)
5. Fibrinogen level 2

Interpretation and Next Steps

Normal PT and aPTT with abnormal bleeding:

• Most likely platelet disorder, particularly von Willebrand disease (the most common inherited bleeding disorder) 1
• Proceed to:
  • Platelet function studies 3
  • von Willebrand factor antigen, ristocetin cofactor activity, factor VIII levels 3, 4
  • Bleeding time (though less commonly used now) 4

Normal PT with prolonged aPTT:

• Indicates intrinsic pathway defect 1, 2
• Perform mixing study to distinguish factor deficiency from inhibitor 1
• If mixing study corrects: factor deficiency (hemophilia A, B, or factor XI deficiency)
• If mixing study doesn't correct: factor inhibitor (acquired hemophilia A) 3

Prolonged PT with normal aPTT:

• Suggests extrinsic pathway disorder 2
• Consider vitamin K deficiency - trial of vitamin K administration 1
• Evaluate for liver disease, warfarin effect 3

Both PT and aPTT prolonged:

• Evaluate for liver failure, DIC, or combined factor deficiencies 1
• Check liver function tests, DIC panel (D-dimer, fibrinogen) 3

Special Populations and Contexts

Patients on Anticoagulation

• For major bleeding on oral anticoagulants, consider reversal agents based on specific drug 3:
  • Warfarin: 4-factor PCC with vitamin K
  • Dabigatran: idarucizumab 5g IV
  • Apixaban/rivaroxaban: andexanet alfa
• For minor bleeding without need for hospitalization, continue anticoagulation but reassess antiplatelet agents 3

Genetic Syndromes

• Cardio-facio-cutaneous syndrome patients require screening for von Willebrand disease and thrombocytopenia if easy bruising present 3
• Ehlers-Danlos syndrome causes capillary fragility; hematologic studies typically normal except abnormal Hess test 5

Immune Checkpoint Inhibitor Therapy

• Easy bruising may indicate immune-related thrombocytopenia or acquired hemophilia A 3
• Requires hematology consultation, may need corticosteroids, IVIG, or factor replacement 3

When Initial Testing is Normal

If high clinical suspicion persists despite normal screening tests: 1, 2

• Refer to hematology for specialized testing including:
  • Platelet aggregation studies
  • Platelet electron microscopy
  • Specific factor assays
  • Evaluation for rare bleeding disorders

Common pitfall: Many women with "easy bruising" and normal platelet counts have either normal platelet function (Type I) or platelet dysfunction with impaired epinephrine/collagen aggregation (Type II), sometimes with elevated antiplatelet antibodies 6

Reassurance for Benign Causes

• Injection-related bruising (insulin, other subcutaneous medications) is usually clinically insignificant 3
• Apply pressure 5-10 seconds to injection sites 3
• Does not adversely affect medication absorption 3