What is the appropriate evaluation and management for a patient who complains of easy bruising?

Evaluation and Management of Easy Bruising

Initial Clinical Assessment

Begin with a targeted bleeding history to determine if laboratory testing is warranted, focusing on significant bleeding after surgery, dental procedures, epistaxis, joint hemorrhages, or menorrhagia, as these symptoms distinguish true bleeding disorders from benign bruising. 1, 2

Critical History Elements

• Medication review: Document all medications including NSAIDs, anticoagulants, antiplatelets, corticosteroids (which cause skin thinning and easy bruisability 3), and alternative therapies, as these affect both bleeding tendency and coagulation test results 1, 2

• Family history: Ask specifically about bleeding disorders in relatives and ethnicity associated with higher rates of certain conditions 2, 4

• Trauma history: Determine if bruising pattern is explained by reported trauma and assess developmental capabilities to determine if bruising location is consistent with normal activity 2

• Pattern and location: Bruising on buttocks, ears, genitals, or patterned bruising has higher specificity for abuse in vulnerable populations and warrants different evaluation 2

Physical Examination Focus

• Evaluate for signs of systemic illness including Ehlers-Danlos syndrome, scurvy, cancer, infiltrative disorders, arteriovenous malformations, or liver disease 2

• Assess for senile purpura in elderly patients (caused by thinning of blood vessels and skin with aging) 1

Laboratory Testing Algorithm

Initial Screening Panel

Order CBC with platelet count, peripheral blood smear, PT, and aPTT as the initial screening panel. 1, 2, 5

• Add fibrinogen level if PT or aPTT are abnormal 1, 2

Interpretation Based on Results

Normal PT and aPTT: High likelihood of von Willebrand disease or platelet function disorder 1

• Proceed with VWD-specific testing: VWF antigen, VWF ristocetin cofactor activity, and Factor VIII coagulant activity 1
• Consider platelet function testing (light transmission aggregometry, flow cytometry) 1

Prolonged aPTT with normal PT: Disorder of intrinsic coagulation pathway 5

• Consider hemophilia (Factor VIII or IX deficiency), particularly in males 1
• Note: Mild hemophilia can cause significant bleeding even if aPTT is not prolonged 1

Prolonged PT with normal aPTT: Disorder of extrinsic coagulation pathway 5

• Consider vitamin K deficiency (particularly in infants without vitamin K prophylaxis at birth) 1
• Evaluate for liver disease/cirrhosis 1

Both PT and aPTT prolonged: Evaluate for liver disease, vitamin K deficiency, or disseminated intravascular coagulation 1

Critical Pitfalls to Avoid

• Do not assume normal PT/aPTT rules out bleeding disorders: These tests miss von Willebrand disease (the most common inherited bleeding disorder with prevalence of 1 in 1000), Factor XIII deficiency, and platelet function disorders 1

• Do not assume normal platelet count excludes platelet disorders: Qualitative platelet defects can cause significant bleeding with normal or even elevated platelet counts 1

• Avoid extensive testing without clinical indication: The extreme rarity of some bleeding disorders makes universal screening unreasonable 2, 4

• Be aware of specimen handling: Coagulation tests are very sensitive to specimen handling and should be performed in experienced laboratories, as inappropriate handling commonly leads to false-positive results 6

• Note aPTT limitations: aPTT can be falsely prolonged with lupus anticoagulant or in Factor XII deficiency (which does not indicate a true bleeding disorder) 6

When to Refer to Hematology

Refer when initial laboratory evaluation indicates a bleeding disorder, high clinical suspicion remains despite normal laboratory workup, specialized testing is needed (platelet function studies, VWD multimer analysis, Factor XIII assay), or complex cases require expert interpretation. 1, 2, 4

Special Populations

Children

• In children with intracranial hemorrhage concerning for abuse, evaluate for bleeding disorders unless independently witnessed trauma or other findings consistent with abuse are present 2
• Laboratory testing suggestive of a bleeding disorder does not eliminate abuse from consideration; follow-up evaluation after change in home setting can provide valuable information 6
• If blood product transfusions have been given, delay screening for bleeding disorders until elimination of transfused clotting elements 6

Preoperative Patients

• Before any surgical procedure, patients with easy bruising should be screened with CBC, platelet count, platelet function study, and von Willebrand screen, even if platelet count is normal 1