Bleeding disorders

Last updated: Thursday, 11, November, 2010
Acquired and inherited causesAppropriate Tests

Note site and nature of bleeding; presence and duration of previous history of surgical, dental, joint, menstrual, mucosal, and skin bleeding; presence of underlying disorder, or use of drugs associated with risk of bleeding. Assess whether bleeding is spontaneous, or inappropriate and/or excessive in relation to trauma.

Assess initially with FBC, PT / INR, APTT, blood film, platelet count, where bleeding is thought to be pathological.

Additional laboratory testing may be indicated by history or the initial test results.

See also Bruising, Purpura, Fibrinolysis.

Acquired bleeding disorders

Advanced and/or metastatic carcinoma

See under Carcinoma.

Blood transfusion related

See under Blood transfusion.

DIC

See under DIC

Drug-related bleeding, especially

  • Anticoagulant therapy
See Anticoagulant monitoring.
  • Fibrinolytic therapy
See Thrombolytic therapy.
  • Aspirin, other NSAID, COX-2 inhibitors
Predictable abnormality of bleeding time and platelet aggregation; these tests do not predict the risk of bleeding and are not indicated.

Thrombocytopenia

Liver disease

See Bleeding under Cirrhosis - consequences.

Myeloproliferative disorders, especially

Neonatal bleeding

Obstetric (peripartum) bleeding

See under Pregnancy.

Paraproteinaemia, multiple myeloma, Waldenstrom's macroglobulinaemia/ lymphoplasmacytic lymphoma

Renal failure

See Bleeding under Renal failure - chronic (complications).

Rodenticide poisoning

See under Poisoning.

SLE

Thrombocytopenia

Inherited bleeding disorders

There is usually a personal and/or family history of bleeding.

Von Willebrand's disase is the most common bleeding disorder. The high incidence is not limited to certain ethnic groups. Mild disorders may present as minor injury or post trauma/surgery bleeding, especially Von Willebrand's disease. Further, Haemophilia A is the second most common inherited coagulopathy.

Initially - FBC, platelet count, blood film; PT/INR, APTT and Factor VIII assay.

Normal results do not exclude the possibility of a clinically significant inherited bleeding disorder. Further investigation should be determined on the basis of the history. Further tests may be indicated from the initial results and, as appropriate, from the history and the degree of clinical suspicion.

The bleeding time is not an effective screening test and a normal BT does not exclude a bleeding disorder.

von Willebrand's disease

Haemophilia A

See under Haemophilia.

Haemophilia B

See under Haemophilia.

Factor XI deficiency

Coagulation factors (XI) assay.

Factor XII deficiency

Coagulation factors (XII) assay; this deficiency is not associated with an increased risk of bleeding.

Factor XIII deficiency

Factor XIII screening test; consult pathologist.

Hypofibrinogenaemia/ afibrinogenaemia

Thrombin time, fibrinogen assay.

Dysfibrinogenaemia

Thrombin time, reptilase time; consult pathologist.

Inherited disorders of platelet function, including

A platelet function screen (PFA-100) may suggest a platelet function disorder. Consult pathologist.
  • Release disorders eg Storage pool disease

Platelet aggregation/release studies. For definitive platelet membrane, granule, and prostaglandin studies - consult pathologist. 

  • Bernard Soulier syndrome

Hereditary haemorrhagic telangiectasia

Clinical diagnosis. Mucocutaneous telangiectases with recurrent bleeding from mucosal surfaces. See also Telangiectases