Approach to the patient with an unusual bleeding
Dr. Mehmood
Unusual bleeding means either relatively excessive bleeding after minor trauma or spontaneous bleed without any trauma
Differential diagnosis:
Hereditary à - Haemophilia
- von Willebrand’s disease
- Bernard-Soulier syndrome
- Platelet storage disorder
Acquired à - Liver disease
- Vitamin K deficiency (Haemorrhagic disease of the newborn, Obstructive jaundice, malabsorption)
- Drugs (Heparin, Warfarin, thrombolytic therapy overdosage)
- Disseminated intravascular coagulation
- Massive transfusion of stored blood
- Thrombocytoenia
- Vasculitis
- Vitamin C deficiency
History
1. Confirm that the patient bleeds unusually!
2. Age: Neonate (Haemorrhagic disease of the newborn likely)
Young patient (Congenital cause likely)
Middle age to Old (Acquired cause likely)
3. Gender: Male (X-linked cause likely)
Female (Autosomal cause likely;Lyonisation)
4. Duration: Acute (Acquired cause likely)
Chronic (Congenital cause likely)
5. Onset: Spontaneous (Coagulopathy likely)
Traumatic (Coagulopathy/Platelet disorders)
Delayed (FXIII deficiency likely)
6. Location of bleed: Epithelial (Platelet disorders more likely than coagulation defect)
Joint spaces/muscle (Clotting factor deficiency likely)
Umbilical stump bleed (Afibrinogenemia, Hypo-/Dysfibrinogenemia, Factor XIII deficiency)
Facial purpura in neonate (Glanzmann thrombasthenia, severe thrombocytopenia)
7. Past Hx: Excessive Bleeding after Tooth extraction/Tonsillectomy /Major surgery (Coagulation defect likely)
Ch. Hepatitis (Liver disease likely)
Snake bite (DIC likely)
Malignancy of Gastrointestinal tract (Liver metastasis likely)
Chronic diarrhea (Malabsorption of Fat-soluble vitamins likely)
Gall stones (Obstructive jaundice/Fat-soluble vitamin deficiency likely)
Fever/repeated infections (Pancytopenia due to aplasia or leukemia likely)
Burns (DIC possible)
Renal stones/Uremia (Platelet function defect likely)
Leukaemia (Relapse)
8. Treatment Hx: Warfarin, Heparin, Thrombolytics, Aspirin (Overdosage likely)
Operation (Delayed bleeding/ peroperative continuous bleeding)
Massive transfusion of stored blood (Dilutional thrombocytopenia and coagulopathy likely)
Cholecystectomy (deficiency of vitamin K due to malabsorption)
9. Family Hx: Males from maternal side affected (X-linked cause likely)
Consanguinity (Autosomal recessive disease likely)
10. Obstetric Hx: Complicated labour (DIC likely)
11. Gynaecologic Hx: No. of pads used (Shows extent of bleed)
Examination
1. Look: Normal/Toxic
2. Consciousness: Grade it. (Poor in DIC, Intracranial bleed, Fulminant hepatic failure)
3. Pulse: For severity of bleed
4. Temp.: For fever (DIC likely)
5. B.P.: Hypotension (DIC)
6. Skin: Petechiae (Platelet disorder likely)
Bruises (Platelet disorder/coagulopathy likely)
Snake bite mark (DIC likely)
7. Joint: Swollen (Haemarthrosis: Coagulopathy likely)
8. Muscle: Swollen (Coagulopathy likely)
8. Operation/trauma site: Poorly healing scab on umbilical stump (FXIII deficiency)
9. Cannula sites: Continuous ooz (DIC likely)
10. Spleen: Massively enlarged (Sequestration of cells)
11. Percussion on abdomen: Ascites in Cirrhosis
12. Liver: Reduced dull note on percussion in cirrhosis
Laboratory Investigation
1. Screening tests:
i. CBC: Thrombocytopenia (Quantitative disorder)
Normal platelet count (Qualitative disorder)
Pancytopenia (Marrow aplasia/Leukaemia)
ii. Peripheral blood morphology: Schistocytes (DIC), Reticulocytosis (DIC), MP (DIC), Blasts,
Giant platelets (BSS)
Coagulation screen
iii. PT: Monitoring of Warfarin. Deficiency of Factor VII, X, V, II, I
iv. aPTT: Monitoring of Heparin. Deficiency of Factor VIII, IX, XII, XI, X, V, II, I
v. Fibrinogen level: Reduced in DIC, A-/Hypo-fibrinogenemi; normal in Dysfibrinogenemia.
vi. TT: Prolonged in Heparin therapy, Fibrinogen defects
vii. CT: Bedside monitoring of Heparin therapy (Obsolete now; replaced by PT & APTT)
viii. BT: Prolonged in reduced Platelet count/function, von Willebrand disease, Factor I defects
ix. FDP: DIC, thrombolysis
x. Hess’s test: Vessel wall defect, thrombocytopenia, platelet function defects
xi. Mixing studies (for detecting most likely coagulation factor deficiency and inhibitors)
xii. Euglobulin clot lysis time
2. Confirmatory tests:
i. Platelet function tests
ii. Factor assays (for confirmation of plasma levels of coagulation factors)
iii. Liver Function Tests
v. Urea solubility test (FXIII deficiency)
3. Additional tests:
Rule out other causes of bleeding which are not considered a bleeding disorder e.g. carcinomas (colon, lung, prostate), peptic ulcer, urinary stones, repeated trauma at wounds, iatrogenic (instrumentation), schistosomiasis.