What is the workup for a patient presenting with excessive bruising?

Workup for Excessive Bruising

Begin with a focused history and physical examination to determine if laboratory testing is warranted, then proceed with initial screening tests (CBC with peripheral smear, PT, aPTT) if a bleeding disorder is suspected based on clinical findings.

Clinical History Assessment

The history should specifically evaluate for:

• Bleeding symptoms suggestive of a disorder: significant bleeding after circumcision or other surgery, epistaxis, bleeding from umbilical stump, excessive bleeding after dental procedures, or joint hemorrhages 1
• Family history of specific bleeding disorders or ethnicity associated with higher rates of certain bleeding disorders 1
• Medication review: document all medications and alternative therapies that may increase bleeding/bruising, as certain drugs can affect coagulation test results 1
• Trauma history: determine if the bruising pattern is explained by reported trauma 1
• Age and developmental capabilities: particularly important in children to assess if bruising location is consistent with normal activity 1

Physical Examination Findings

Key examination elements include:

• Location and pattern of bruising: bruising on buttocks, ears, genitals, or patterned bruising has higher specificity for abuse in children and warrants different evaluation 1
• Mucocutaneous bleeding (petechiae, gingival bleeding) suggests platelet dysfunction 2, 3
• Hemarthroses or deep hematomas suggest coagulopathy rather than platelet disorders 2, 3
• Signs of systemic illness: evaluate for Ehlers-Danlos syndrome, scurvy, cancer, infiltrative disorders, or arteriovenous malformations 1

When Laboratory Testing is NOT Required

Laboratory evaluation for bleeding disorders is generally excluded when: 1

• The caregiver's description of trauma sufficiently explains the bruising
• The patient or independent witness provides a history of trauma that explains the bruising
• Patterned bruising consistent with abuse is present (e.g., patterned slap mark with corroborating history)

Initial Laboratory Screening Panel

When clinical suspicion warrants testing, the initial screening includes: 1, 2, 3

• Complete blood count (CBC) with platelet count to screen for thrombocytopenia and immune thrombocytopenia (ITP)
• Peripheral blood smear to evaluate platelet morphology and identify abnormalities
• Prothrombin time (PT) to assess extrinsic and common coagulation pathways
• Activated partial thromboplastin time (aPTT) to assess intrinsic and common coagulation pathways
• Fibrinogen level if PT or aPTT are abnormal 1

Important caveat: Most factor deficiencies can be detected by PT and aPTT; however, von Willebrand disease (VWD) and factor XIII deficiency are NOT reliably detected by these screening tests 1. Mild hemophilia (factor VIII or IX deficiency) might not cause aPTT abnormalities but can still result in significant bleeding 1.

Interpretation Algorithm

Normal PT and aPTT: Suggests platelet disorder, most commonly von Willebrand disease; proceed with VWD-specific testing 2, 3

Normal PT with prolonged aPTT: Indicates intrinsic pathway deficit; perform mixing study to differentiate factor deficiency from inhibitor 2, 3

Prolonged PT with normal aPTT: Consider vitamin K deficiency; vitamin K challenge is indicated 2, 3

Prolonged PT and aPTT: Workup for liver failure, disseminated intravascular coagulation (DIC), or combined factor deficiencies 1, 2

Special Considerations for Intracranial Hemorrhage

Children with intracranial hemorrhage (ICH) concerning for abuse require evaluation for bleeding disorders, with exceptions including: 1

• Independently witnessed or verifiable trauma (abusive or nonabusive)
• Other findings consistent with abuse (fractures, burns, internal abdominal trauma)

In nonmobile infants, ICH is highly concerning for child abuse, and consultation with a child abuse pediatrician should be considered in complex cases 1.

Additional Testing Considerations

Vitamin K deficiency testing: In infants with prolonged PT, measure proteins induced by vitamin K absence, particularly if vitamin K was not administered at birth or if there are predisposing medical conditions 1

Platelet function testing: The platelet function analyzer (PFA-100) can screen for platelet disorders but has limitations; many centers have decreased its use, and consultation with a pediatric hematologist is recommended for interpretation 1

DIC evaluation: If DIC is suspected (can cause any type of bruising/bleeding including ICH), consider the multitude of primary causes including trauma, sepsis, and primary bleeding disorders 1

Referral Indications

Refer to hematology when: 2, 3

• Initial laboratory evaluation indicates a bleeding disorder
• High clinical suspicion remains despite normal laboratory workup
• Specialized testing is needed (platelet aggregation studies, specific factor assays, VWD testing)
• Complex cases requiring expert interpretation