hematology and oncology
Excessive Bleeding
Evaluation of Excessive Bleeding
History of present illnessshould determine the bleeding sites, the amount and duration of bleeding, and the relationship of bleeding to any possible precipitating events, including drug exposure. Review of systemsshould specifically query about bleeding from sites other than those volunteered (eg, patients complaining of easy bruising should be questioned about frequent nosebleeds, gum bleeding while tooth brushing, melena, hemoptysis, blood in stool or urine). Patients should be asked about symptoms of possible causes, including abdominal pain and diarrhea (gastrointestinal illness); joint pain (connective tissue disorders); and amenorrhea plus morning sickness (pregnancy). Past medical historyshould seek known systemic conditions associated with defects in platelets or coagulation, particularly Severe infection, cancer, Cirrhosis , Prior excessive or unusual bleeding or transfusions Family history of excessive bleeding Medication and drug history should be reviewed, particularly use ofheparin,warfarin, P2Y12 inhibitors, direct oral inhibitors ofthrombinorfactor Xa(eg,apixaban,edoxaban,rivaroxaban),aspirin, and NSAIDs. Patients who are takingwarfarinalso should be questioned about intake of other medications, drugs, toxins, and foods (including rodent poison and herbal supplements) that impair the metabolism ofwarfarinand thus increase its anticoagulant effect. Vital signs and general appearance can indicate hypovolemia (tachycardia, hypotension, pallor, diaphoresis) or infection (fever, tachycardia, hypotension with sepsis). The skin and mucous membranes (nose, mouth, vagina) are examined for petechiae, purpura, and telangiectasias. Gastrointestinal bleeding can often be identified by digital rectal examination with fecal occult blood testing. Signs of bleeding in deeper tissues may include tenderness during movement and local swelling, muscle hematomas, and, for intracranial bleeding, confusion, stiff neck, focal neurologic abnormalities, or a combination of these findings. Characteristic findings of chronic excessive alcohol use or liver disease are telangiectases, ascites, splenomegaly (secondary to Portal Hypertension ), and jaundice. The following findings are of particular concern: Signs of Volume Depletion or Pregnancy or recent delivery Signs of infection or sepsis Bleeding in a patient takingwarfarinis especially likely if there has been a recent increase in dose or the addition of a medication or food that may interfere withwarfarininactivation. Telangiectasias on the face, lips, oral or nasal mucosa, and tips of the fingers and toes in a patient with a positive family history of excessive bleeding is likely to indicate Hereditary Hemorrhagic Telangiectasia . Bleeding from superficial sites, including skin and mucous membranes, suggests a quantitative or qualitative defect in platelets or a defect in blood vessels (eg, Amyloidosis , Bleeding into deep tissues (eg, hemarthroses, muscle hematomas, retroperitoneal hemorrhage) suggests a defect in coagulation (coagulopathy). A family history of excessive bleeding suggests an inherited coagulopathy (eg, Hemophilia ), a qualitative platelet disorder, a type of Bleeding in a patient who is pregnant or has recently delivered, who is in shock, or who has a serious infection suggests Disseminated Intravascular Coagulation (DIC) (DIC). Bloody diarrhea and thrombocytopenia in a patient with fever and gastrointestinal symptoms suggest the Hemolytic-Uremic Syndrome (HUS) (HUS), which is often associated with infection by In a child, a palpable, purpuric rash on the extensor surfaces of the extremities suggests Immunoglobulin A–Associated Vasculitis (IgAV) , particularly if accompanied by fever, polyarthralgia, or gastrointestinal symptoms. Patients with known alcohol use disorder or liver disease may have coagulopathy, splenomegaly, or thrombocytopenia. Patients with a history of use of IV illicit drugs or unprotected sexual exposure may have an Human Immunodeficiency Virus (HIV) Infection . Most patients require laboratory evaluation (see table). The initial tests are Complete blood count (CBC) with platelet count Peripheral blood smear Prothrombin time (PT) and partial thromboplastin time (PTT) ). The most common screening tests for bleeding disorders are the platelet count, PT, and PTT. If results are abnormal, a specific test can usually pinpoint the defect. Determination of the level of fibrin degradation products measures in vivo activation of fibrinolysis (usually secondary to excessive coagulation in Disseminated Intravascular Coagulation (DIC) ). 3 seconds longer than a laboratory’s normal control value is usually abnormal and requires further evaluation. The PT is valuable in screening for abnormal coagulation in various acquired conditions (eg, Vitamin K Deficiency , liver disease, DIC). The INR is used to monitor therapy with the oral vitamin K antagonist, therapy. Inhibitors that prolong the PTT include an autoantibody against factor VIII (see also Hemophilia and Prolongation of PT or PTTmay reflect Clotting factor deficiency Presence of an inhibitor of a component of the coagulation pathway (including the presence in circulation of a direct oral anticoagulant inhibitingthrombinorfactor Xa) The PT and PTT do not become prolonged until one or more of the clotting factors tested are about 70% deficient. For determining whether prolongation reflects a deficiency of one or more clotting factor or the presence of an inhibitor, the test is repeated after mixing the patient’s plasma with normal plasma in a 1:1 ratio. Because this mixture contains at least 50% of normal levels of all coagulation factors, failure of the mixture to correct the prolongation almost completely suggests the presence of an inhibitor in patient plasma. The bleeding time test is not sufficiently reproducible to be reliable for clinical decision-making. on initial tests exclude many bleeding disorders. The main exceptions are Von Willebrand Disease and ). If the smear shows no evidence of other abnormalities, patients should be tested for Human Immunodeficiency Virus (HIV) Infection . If the result of the HIV test is negative and the patient is not pregnant and has not taken a medication known to cause platelet destruction, then suggests Hemophilia . Factor VIII, IX, and XI assays are indicated. Inhibitors that specifically prolong the PTT include an autoantibody against factor VIII and antibodies against protein-phospholipid complexes (lupus anticoagulant). Clinicians suspect one of these inhibitors when a prolonged PTT does not correct after 1:1 mixing with normal plasma. anticoagulation or in patients with early Vitamin K Deficiency or incipient liver disease. suggest Disseminated Intravascular Coagulation (DIC) , especially in association with obstetric complications, occurs with liver disease or Vitamin K Deficiency or during anticoagulation with Imaging testsare often required to detect occult bleeding in patients with bleeding disorders. For example, CT of the head should be done in patients with severe headaches, head injuries, or impairment of consciousness. Abdominal CT is needed in patients with abdominal pain or other findings compatible with intraperitoneal or retroperitoneal hemorrhage. 