Clinical Evaluation of Bleeding and Bruising in Primary Care

 


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Am Fam Physician. 2016 Feb 15;93(4):279-286.

  Patient information: See related handout on easy bruising and bleeding, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Bleeding and bruising are common symptoms in the primary care setting. The patient history can help determine whether the bruising or bleeding is abnormal. The International Society on Thrombosis and Hemostasis has developed a bleeding assessment tool that can be used to indicate possible pathology. A family history of bleeding problems may suggest a hereditary coagulation defect. Such a history is especially important in children who may not have experienced a major bleeding episode. Medication review can identify pharmacologic causes of the bleeding or bruising. 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. If the history and physical examination findings suggest a bleeding diathesis, initial laboratory testing includes a complete blood count, peripheral blood smear, prothrombin time (PT), and partial thromboplastin time (PTT). A normal PT and PTT indicate a platelet disorder, the most common of which is von Willebrand disease. A normal PT and prolonged PTT signal a deficit in the intrinsic pathway, and a mixing study should be performed. A vitamin K challenge is indicated in patients with an abnormal PT and normal PTT. A workup for liver failure is warranted in patients with prolonged PT and PTT. 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.

Easy bruising and abnormal bleeding are common symptoms in the primary care setting that may present as excessive bruising when injured, or as epistaxis, menorrhagia, or prolonged bleeding during surgery or dental procedures. It is estimated that 26% to 45% of healthy patients have a history of epistaxis, easy bruising, or gum bleeding.1 Approximately 5% to 10% of reproductive-aged women seek treatment for menorrhagia,2 and an estimated 29% of these women have an underlying bleeding disorder.3,4 Women with von Willebrand disease are five times more likely to have menorrhagia than those without the condition.5 Although von Willebrand disease affects men and women equally, women are more likely to seek evaluation because of heavy menses.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The ISTH-BAT should be used during the initial evaluation of patients with a suspected bleeding disorder.

C

11, 12

A peripheral blood smear, complete blood count, prothrombin time, partial thromboplastin time, and renal and liver function tests should be obtained in patients with an abnormal ISTH-BAT score or in whom a bleeding disorder is suspected.

C

1820

Patients should be referred to a hematologist for further evaluation if suspicion for a bleeding disorder remains high despite a negative workup.

C

15


ISTH-BAT = International Society on Thrombosis and Hemostasis Bleeding Assessment Tool.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The ISTH-BAT should be used during the initial evaluation of patients with a suspected bleeding disorder.

C

11, 12

A peripheral blood smear, complete blood count, prothrombin time, partial thromboplastin time, and renal and liver function tests should be obtained in patients with an abnormal ISTH-BAT score or in whom a bleeding disorder is suspected.

C

1820

Patients should be referred to a hematologist for further evaluation if suspicion for a bleeding disorder remains high despite a negative workup.

C

15


ISTH-BAT = International Society on Thrombosis and Hemostasis Bleeding Assessment Tool.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Identification of bleeding and bruising and appropriate intervention can decrease the associated morbidity and mortality. Evaluation of the patient with bleeding and bruising requires a detailed personal and family history, a thorough review of medications, physical examination, and laboratory testing.

Mechanisms of Bleeding and Bruising

Bleeding occurs when there is a disruption in blood vessel walls. In healthy individuals, if the endothelial defect is not too large, exposed subendothelial proteins interact with coagulation factors

The Authors

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DANA NEUTZE, MD, PhD, is an assistant professor at the University of North Carolina at Chapel Hill Family Medicine Residency Program....

JODI ROQUE, MD, is an assistant professor at the University of North Carolina at Chapel Hill Family Medicine Residency Program, and also practices at Piedmont Health Services, Prospect Hill (N.C.) Community Health Center.

The authors thank Anthony Viera, MD, MPH, and George Fedoriw, MD, for their assistance with the manuscript.

Address correspondence to Dana Neutze, MD, PhD, University of North Carolina at Chapel Hill, 590 Manning Dr., Chapel Hill, NC 27599 (e-mail: dana_neutze@med.unc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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