Easy Bruising / Easy Bleeding

We’ll begin by addressing the common complaint of Easy Bruising.  Most patients don’t require any testing, but those who do get the same work-up as for Easy Bleeding.  The medical term for “bruise” is “ecchymosis” (pl. ecchymoses), but there’s no Latin or Greek prefix to generate additional medicalese, so we simply say “Easy Bruising.”

Since the blood in an ecchymosis has extravasated from capillaries, it doesn’t blanche.  Before we go on, differentiate an ecchymosis from petichiae & purpura, which don’t blanche either.  Both occur in crops or clusters.  Petichiae are pinpoint lesions; purpura, sometimes palpable, are larger and deeper than ecchymoses.  They require work-up for vasculitis (beyond today’s scope).

In terms of Easy Bruising, the broad differential for clinicians to distinguish among can be lumped into 3 categories:

• Normal Bruising
• Physical Abuse
• Bleeding Disorders

It would seem as if “normal” would be a diagnosis of exclusion, but actually not.  On average, studies find 20% of healthy adults experience easy bruising, women more than men, light-skinned more than dark-skinned.  Pathologic causes are rare, and can be quite expensive to work up.  So we invariably are able to reassure patients with minimal if any testing.

Let’s rule out Physical Abuse to begin.  For one, a patient who’s abused won’t complain about “easy bruising,” because they know the cause.  Perhaps you notice the bruises during an exam, and the patient feigns ignorance.  Clues to domestic violence (upon a partner, elder, child) include:

• Discomfort discussing the bruises
• Inappropriate affect
• Explanation of mechanism not compatible with injury
• Geographic bruises (match specific assaults, e.g. choking, belt, etc.)

Once confident that physical abuse is not an issue, examine the location of bruises.  Normal bruising presumably occurs from unrecognized minor trauma, which invariably involves the extremities alone, especially from elbows / knees on down.  If loved ones assist with ambulation, normal bruises may occur on the upper arms, especially the elderly with fragile skin.

A number of medications predispose to bruising.  These include:

• Aspirin (even just one per week)
• NSAIDs
• SSRIs & SNRIs (anti-depressants)
• Steroids (long-term systemic)
• Anticoagulants & anti-platelet agents (duh)

Identify any, and a discontinuation trial might be warranted, if possible.  Cardioprotective aspirin could be discontinued several weeks, then rechallenged as a diagnostic trial in order to obviate additional work-up.  Bupropion might be substituted for an SSRI.

In general, we simply reassure the patient with easy bruising of extremities, as long as we rule out:

Red Flags suggesting Bleeding Disorder

• ≥5 bruises that are >1 cm. diameter
• Any unexplained palm-sized bruise
• Frequent epistaxis or gingival bleeds
• Menorrhagia or Metrorrhagia
• Bleeding complications from prior dental work or surgery
• History of atraumatic hemarthrosis
• Alcoholic, Malnourished
• Family history of bleeding disorder

Find any of these, and some testing is required.  As you can see, complaints of “Easy Bleeding” are included here.  First step is simply:

• Platelet count (but include entire CBC with Differential)
• Prothrombin Time (PT)
• Partial Thromboplastin Time (PTT) [technically “activated-PTT”]

Platelet Count

BEWARE the “normal-low” platelet count (for want of another term).  Bruising may occur when platelets drop below 30,000/mcL, but significant bleeding doesn’t happen until they drop below 10,000.  Normal platelets are around 150,000 to 400,000, but “low” of, say, 80,000 is not the cause of bleeding / bruising.  It should still be investigated in its own right; some common causes include HIV, ITP, early cirrhosis, acute viral infections, and SLE.

BEWARE also the spuriously-low count (pseudothrombocytopenia).  Never conclude anything about platelets without a peripheral smear, which will note if there are “platelet clumps.”  This happens to some people’s blood when exposed to EDTA in the test tube (so there are really lots of platelets, but the clumps don’t get counted by the machine).

If the lab report doesn’t mention “clumping,” it should say something like, “platelet count confirmed by peripheral smear,” meaning that a tech eyeballed it.  If there’s no mention of this, call the lab & request it (usually done reflexively for low platelets).  If clumps are present, you can redraw the test in a tube with a different anticoagulant from EDTA, which may be hard to obtain and is probably not necessary.  Don’t order a “manual platelet count,” which is very labor-intensive.

If the platelet count is <30,000/mcL in a patient with easy bruising / bleeding, it’s probably due to idiopathic thrombocytopenia (ITP), provided that the WBCs and RBCs are normal (if low, hematology will need to examine bone marrow).  Main rule-outs are:

• HIV (any stage of infection)
• Drug-Induced Thrombocytopenia (DITP)

DITP can be caused by all sorts of unlikely substances, from prescription meds to OTCs, herbals, quinine (in tonic water), MMR vaccine, peanuts, and more.  Onset occurs 1-10 days after ingestion (median is 8), recovery averages a week post-discontinuation.  Diagnosis is made completely by history, based on the temporal relationship, especially in cases with recurrence.  If the culprit is likely to be needed / ingested in the future, send to Hematology to discuss utility / danger of rechallenge (in a controlled setting!).

Patients over 60 years-old with low platelets may benefit from a Hematology consult anyway, to r/o Myelodysplastic Syndrome.  Usually there’s something abnormal in the CBC or peripheral smear, maybe as subtle as a high MCV.  Still, based on age alone, I’d let Heme decide about need for bone marrow exam.

PT and PTT

Numerous coagulation disorders can make either or both of these tests abnormal.  In primary care, I tend to refer to Heme.  If only the PT is high (INR ≥1.5), I draw liver function tests, and work those up if abnormal (see posts Acute Hepatitis and Chronic Hepatitis).  If you want to work up the bleeding disorder yourself, various texts & tables will point your way.

[Bleeding Time]  —  Don’t order it.  There’s no good standardization, and it’s technically challenging.  I’d never trust a result.

Von Willebrand’s Disease

Here’s a special case, because the condition affects about 1% of the US population, although in only 1% of those is it serious (1 in 10,000 overall).  The Platelet Count, PT and PTT are often all normal.  So anyone with a history of excessive bleeding might warrant a work-up; certainly anyone who’s ever required an unexpected transfusion.

Labs usually have a “Von Willebrand’s Panel” available to order.  If not, order tests separately:

• Von Willebrand factor Antigen
• Plasma VWF activity (aka Ristocetin Cofactor activity)
• Factor VIII activity

If either of the first two tests are low (<30 IU/dL), you have your diagnosis.  Factor VIII may be normal; if frankly low, the PTT is usually abnormal too.

SUMMARY

1. r/o Physical abuse
2. r/o Red Flags
3. Reassure (esp. if bruising isolated to extremities)

• Obtain Platelet Count (with CBC), PT, PTT
• If Platelets low but >30,000, NOT cause of bleed (but W/U anyway)
• If Platelets <30,000/mcrL:
  • Obtain HIV antibody
  • r/o Drug-Induced Thrombocytopenia (history)
  • If low WBC / RBC → to Heme
  • Isolated low Platelets → Dx ITP → to Heme for Tx if <30,000
• If PT and/or PTT elevated:
  • Obtain LFTs, work-up if abnormal
  • Send to Heme
• Platelets, PT, PTT all normal → r/o von Willebrand’s
  •  Von Willebrand factor Antigen
  • Plasma VWF activity (aka Ristocetin Cofactor activity)
  • Factor VIII activity
• No Diagnosis, & concerned re Easy Bleeding → to Heme

• Platelets, PT, PTT all likely normal
• Simple Initial Tests: CBC, ESR, ANA, Hep B & C serologies
• Send to Rheumatology
• May benefit from biopsy

And that’s it for today; hope it was bloodless.