What is the investigation for easy bruising, also known as ecchymosis (easy bruising)?

From the Guidelines

An investigation for easy bruising should begin with a thorough medical history and physical examination, followed by a complete blood count (CBC), peripheral blood smear, prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet function tests, as recommended by recent guidelines 1. The initial workup is crucial in identifying potential causes of easy bruising, such as coagulation factor deficiencies, platelet disorders, or vascular abnormalities.

• A thorough medical history should include questions about medication use, particularly anticoagulants like warfarin, heparin, and direct oral anticoagulants, as well as antiplatelet drugs like aspirin and clopidogrel.
• Additional tests may include von Willebrand factor assay, factor VIII and IX levels, and bleeding time, as suggested by studies on bleeding disorders 1.
• For patients with normal initial test results but persistent symptoms, more specialized tests such as platelet aggregation studies or genetic testing for rare bleeding disorders may be warranted.
• Vitamin K deficiency and liver disease should also be considered as potential causes, and patients should be advised to avoid NSAIDs during the investigation period as these can worsen bleeding tendencies by inhibiting platelet function. The investigation aims to distinguish between different causes of easy bruising and provide a diagnosis that can guide treatment and management, ultimately improving patient outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Investigation for Easy Bruising

The investigation for easy bruising involves a comprehensive approach, including:

• A detailed history to identify potential underlying disorders 2
• A comprehensive physical examination to evaluate evidence of bleeding and identify systemic illness 3
• Laboratory studies, such as a complete blood cell count, peripheral blood smear, prothrombin time (PT), and activated partial thromboplastin time (aPTT) 4, 5, 6
• Use of a bleeding assessment tool to help identify causes of abnormal bleeding and bruising 4, 5
• Family history to aid in the diagnosis of a heritable cause 4, 5, 6
• Medication review to identify pharmacologic causes of bleeding or bruising 5

Laboratory Testing

Laboratory testing may include:

• Complete blood count to evaluate for thrombocytopenia or other abnormalities 4, 5, 6
• Peripheral blood smear to evaluate platelet morphology and detect any abnormalities 4, 5, 6
• Prothrombin time (PT) and activated partial thromboplastin time (aPTT) to evaluate coagulation factors 4, 5, 6
• Fibrinogen level to evaluate for coagulopathy 4
• Von Willebrand factor antigen, von Willebrand factor activity, and template bleeding time to diagnose von Willebrand disease 6

Referral to a Specialist

Referral to a hematologist or other specialist may be necessary if:

• Initial evaluation indicates a bleeding disorder 4, 5
• Suspicion of a bleeding disorder remains high despite a normal laboratory workup result 4
• Patient has a complex medical history or multiple potential causes of bleeding or bruising 2