What could be causing my easy bruising and how can it be managed, especially if I have a history of bleeding disorders or am taking anticoagulants (blood thinners) or antiplatelet agents?

Easy Bruising: Causes and Management

Primary Causes to Consider

Easy bruising most commonly results from von Willebrand disease (the most prevalent inherited bleeding disorder affecting ~1 in 1000 people), medication effects (anticoagulants, antiplatelets, NSAIDs, steroids), or platelet dysfunction—even when platelet counts are normal. 1

Bleeding Disorders

• Von Willebrand disease presents with mucocutaneous bleeding and easy bruising but is NOT detected by routine PT/aPTT screening 1, 2
• Hemophilia (Factor VIII or IX deficiency) causes significant bruising even with mild deficiencies, particularly in males 1
• Immune thrombocytopenia (ITP) is characterized by low platelet count and is often self-resolving 1
• Platelet function disorders can occur with normal or even elevated platelet counts, requiring specialized testing like platelet aggregation studies 1, 3
• Factor XIII deficiency is not detected by standard PT/aPTT tests but causes significant bruising 1

Medication-Related Causes

• Anticoagulants (warfarin, DOACs) are major contributors to bleeding risk, with elderly patients requiring ~1 mg/day less warfarin than younger individuals 4
• Antiplatelet agents (aspirin, P2Y12 inhibitors) increase bruising tendency, though routine platelet transfusion is NOT recommended for bleeding on antiplatelets 4
• NSAIDs impair platelet function, produce gastric erosions, and in high doses impair vitamin K-dependent clotting factor synthesis 4
• Corticosteroids and certain antibiotics increase bruising tendency 1

Other Medical Conditions

• Liver disease/cirrhosis decreases clotting factor production; PT, INR, and aPTT may be unreliable in this setting, and viscoelastic testing (TEG/ROTEM) may be valuable 4, 1
• Vitamin K deficiency is particularly important in infants without prophylaxis at birth, presenting with prolonged PT 1
• Ehlers-Danlos syndrome (vascular subtype) causes capillary fragility and can lead to spontaneous arterial rupture; standard coagulation studies are typically normal except for the Hess test 5
• Senile purpura results from thinning blood vessels and skin with aging 1

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Diagnostic Approach

History and Physical Examination

• Document bleeding symptoms including significant bleeding after surgery/dental procedures, epistaxis, joint hemorrhages, or menorrhagia 2
• Obtain family history of bleeding disorders or ethnicity associated with higher rates of specific disorders 2
• Review ALL medications including NSAIDs, anticoagulants, antiplatelets, steroids, and alternative therapies 2
• Assess bruising pattern and location: bruising on buttocks, ears, genitals, or patterned bruising has higher specificity for abuse in children 2
• Evaluate for systemic illness signs including Ehlers-Danlos syndrome, scurvy, cancer, or arteriovenous malformations 2

Initial Laboratory Testing

Order CBC with platelet count, peripheral blood smear, PT, aPTT, and fibrinogen level (if PT or aPTT abnormal) as the initial screening panel. 2, 6, 7

• Normal PT and aPTT indicate a platelet disorder (most commonly von Willebrand disease); proceed with VWD-specific testing including VWF antigen, VWF ristocetin cofactor activity, and Factor VIII coagulant activity 1, 6
• Normal PT with prolonged aPTT signals intrinsic pathway deficit; perform a mixing study 6, 7
• Prolonged PT with normal aPTT suggests extrinsic pathway disorder; consider vitamin K challenge 6, 7
• Both PT and aPTT prolonged warrants evaluation for liver disease, vitamin K deficiency, or DIC 1, 7

Critical Testing Limitations

• PT and aPTT do NOT reliably detect von Willebrand disease or Factor XIII deficiency, making additional testing necessary when clinical suspicion remains high 1, 2
• Platelet function analyzer (PFA-100) can screen for platelet disorders but has limitations; hematology consultation is recommended for interpretation 2
• Review peripheral blood smear to assess platelet morphology and identify altered size/structure suggesting inherited platelet function disorders 1

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Management Strategies

For Patients on Anticoagulants

Nonmajor Bleeding

• Do NOT routinely reverse anticoagulation for nonmajor bleeds 4
• Temporarily discontinue anticoagulation until clinically stable and hemostasis achieved 4
• Apply local measures to control bleeding wherever possible 4
• Consider these factors before holding anticoagulation: Is anticoagulation supratherapeutic? Is an invasive procedure needed soon? Has underlying bleeding risk changed (new medications, renal/hepatic dysfunction)? 4

Major Bleeding

• For warfarin: Give 4-factor prothrombin complex concentrate (PCC) with vitamin K 10 mg slow IV infusion 4, 8
• For dabigatran: Administer idarucizumab 5g IV 8
• For apixaban/rivaroxaban: Use andexanet alfa 8
• Transfuse RBCs to maintain hemoglobin ≥7 g/dL (≥8 g/dL in coronary artery disease/acute coronary syndromes) 4
• Avoid routine platelet transfusion for bleeding on antiplatelet agents, as trials show higher odds of death or dependence with platelet transfusion in ICH 4

For Patients with Bleeding Disorders

• Refer to hematology when initial laboratory evaluation indicates a bleeding disorder, high clinical suspicion remains despite normal workup, or specialized testing is needed 1, 2
• Preoperative screening should include CBC, platelet count, platelet function study, and von Willebrand screen even if platelet count is normal 1
• Acquired von Willebrand syndrome (occurring with high platelet counts) may require desmopressin or von Willebrand factor concentrates 1

Special Considerations

• Minimize injection-related bruising by applying pressure 5-10 seconds to injection sites 8
• Monitor patients on divalproex sodium with platelet counts every 6 months 8
• Consider anti-fibrinolytic agents (tranexamic acid or epsilon aminocaproic acid) in appropriate clinical contexts 4
• Use plasma cautiously in portal hypertension/esophageal varices, as large volumes may increase portal pressure and exacerbate bleeding 4

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Common Pitfalls to Avoid

• Do NOT assume normal PT/aPTT rules out bleeding disorders, as these tests miss von Willebrand disease, Factor XIII deficiency, and platelet function disorders 1
• Do NOT overlook mild hemophilia (mild Factor VIII or IX deficiency), which can cause significant bleeding even with non-prolonged aPTT 1
• Do NOT perform extensive testing without clinical indication, as extreme rarity of some bleeding disorders makes universal screening unreasonable 2
• Do NOT ignore medication effects, as certain drugs affect both bleeding tendency and test interpretation 2
• Do NOT routinely lower blood pressure in acute nosebleeds, as excessive reduction may cause renal, cerebral, or coronary ischemia 4