From the Guidelines
The workup for easy bruising should start with a detailed medical history and physical examination, followed by laboratory testing including a complete blood count, coagulation studies, and liver function tests, as recommended by the most recent guidelines 1. The initial evaluation should focus on identifying underlying causes of easy bruising, such as medication use, family history of bleeding disorders, and timing/pattern of bruising.
- A thorough medical history should be taken, including questions about medication use, especially blood thinners like warfarin, aspirin, or NSAIDs, as well as family history of bleeding disorders.
- Physical examination should assess for signs of systemic disease and document bruise characteristics, including location, size, and shape.
- Laboratory testing should include a complete blood count to check platelet levels, coagulation studies (PT/INR, PTT) to evaluate clotting function, and liver function tests since liver disease can affect clotting factor production.
- For persistent or severe cases, additional specialized tests may be ordered, such as von Willebrand factor assay, factor VIII and IX levels, or platelet function tests, as suggested by studies on von Willebrand disease 1.
- If medication-induced bruising is suspected, consider medication adjustment under medical supervision, and nutritional factors like vitamin K or vitamin C deficiency may be evaluated in some cases.
- Most easy bruising is benign and related to aging, thin skin, or minor trauma, but persistent or severe bruising warrants medical evaluation to rule out serious underlying conditions like leukemia, hemophilia, or von Willebrand disease, as highlighted in studies on bleeding disorders in children 1.
From the Research
Initial Evaluation
- The workup for easy bruising typically begins with a comprehensive history and physical examination to determine whether the bruising is abnormal 2, 3.
- A family history of bleeding problems may suggest a hereditary coagulation defect, and medication review can identify pharmacologic causes of the bleeding or bruising 2, 3.
- Physical examination findings such as mucocutaneous bleeding suggest that the underlying condition is caused by platelet dysfunction, whereas hemarthroses or hematomas are more common in coagulopathy 2.
Laboratory Testing
- Initial laboratory testing includes a complete blood count, peripheral blood smear, prothrombin time (PT), and partial thromboplastin time (PTT) 2, 3.
- A normal PT and PTT indicate a platelet disorder, the most common of which is von Willebrand disease 2.
- A normal PT and prolonged PTT signal a deficit in the intrinsic pathway, and a mixing study should be performed 2.
- A vitamin K challenge is indicated in patients with an abnormal PT and normal PTT 2.
Specific Conditions
- Thrombocytopenia, a platelet count of less than 150 × 10^3 per μL, can occur from decreased platelet production, increased destruction, splenic sequestration, or dilution or clumping 4.
- Patients with thrombocytopenia may have mild skin manifestations such as petechiae, purpura, or ecchymosis, and those with platelet counts of less than 10 × 10^3 per μL have a high risk of serious bleeding 4.
- Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) and disseminated intravascular coagulation (DIC) may have identical manifestations in adults, but can be distinguished by platelet count and prothrombin time 5.
Further Evaluation
- If initial testing does not reveal an etiology in a patient with a high suspicion for a bleeding disorder, the patient should be referred to a hematologist for additional evaluation 2, 3.
- A workup for liver failure is warranted in patients with prolonged PT and PTT 2.
- Consultation with a hematologist is recommended when initial evaluation indicates a bleeding disorder or when suspicion remains high despite a normal laboratory workup result 3.