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Bruising – Excluding NAI

Bruising in the elderly is a common presentation. This chart on A4Medicine can be helpful in data gathering and plan further investigations based on clinical suspicion. The clinician should consider Vitamin C deficiency as an easily treatable cause of bruising.Perio-orbital bruising can be a presentation of  Nueroblastoma in children and should alert the clinician to examine the child further. A list of possible first line investigations is also available. Senile purpura is a common cause of bruising in the elderly.

Common problem Bruise – haematoma which forms due to bleeding under intact skin in s/c tissue due to vascular damage or injury Damage that causes bleeding can be
○ trauma external to vessel
○ internal to the vessel
○ vessel itself Colour changes
Red discoloration → purple → brownish yellow Usually disappears within 2-3 weeks A detailed history often provides sufficient information Bruising is reported ↑ frequently by women than men

History-What does the patient mean Circumstances -spontaneous or following trauma ? dental procedures Age of manifestation General overall health
○ past medical history
○ past surgical history- all operations , dental extractions etc Type of bleeding ie epistaxis , menorrhagia or hematomas Any petechiae or purple patches ( purpura ) with bruises Nutritional status Alcohol use or risk factors for chronic liver disease Prescribed and OTC drug history Family history – particularly
○ bleeding disorders –> haemophilia ( rare 1 in 5000 ) , von Willerbrand’s disease or a platelet disorder
○ tendency to bruise or bleed easily or spontaneously
○ menorrhagia or post-partum bleeding – may indicated non sex linked dis as von Willerbrands or factor XI deficiency
○ consanguinity ↑ risk autosomal recessively inherited disorders as factor X deficiency
○ Hereditaey haemorrhagic telangiectasia , Ehler-Danlos syndrome or osteogenesis imperfecta Colour of bruising
 not a reliable indicator of age

Examination-Location and pattern of bruising
○ distribution , number , site , shape 
○ presence of petechiae and ecchymoses
○ dependent areas – thrombocytopenia or stasis factors
○ atypical areas eg on trunk ( consider bleeding disorder or NAI _
○ patterned bruising eg hand print or belt
○ distribution for eg- only on arms and legs ( trauma or changes in skin and s/c tissue )
○ location – dorsum of hands , extensor surface of the forearms and the shins → senile purpura Signs of malnutrition ( brittle hairs , nails , cachexia ) Joints ( haemarthroses ) Abdomen ( signs of chronic liver disease ) Oral cavity ( gum hyperplasia , periodantal inflammation -Vit C deficiency ) Lymphadenopathy

Causes- Trauma Consider accidental and non-accidental injuries Cupping or coining may contribute towards it   Vascular- Senile purpura ( common ) Senile purpura ( easy bruising syndrome ) young ♀ Hereditary haemorrhagic telangiectasia ( HHT – rare ) Ehler-Danlos syndrome Osteogenesis imperfecta Vitamin C deficiency ( Scurvy )   Platelet disorders -Acute idiopathic thrombocytopenic purpura ( ITP ) Chronic ITP Henoch-Schlonlein purpura ( HSP ) Aplastic anaemia Malignancy End stage CKD Liver disease    Coagulation -May be inherited or acquired
Negative family hx → does not r/o genetically inherited disorder
 Haemophilia A ( Factor VIII deficiency ) and Haemophilia B 
( factor IX deficiecny ) Liver disease Vitamin K deficiency Von Willerbrand’s disease- most common inherited coagulation disorder prevalence 1-2 % gen population Amyloidosis  Drugs-Corticosteroids Platelet inhibitors
○ aspirin
○ NSAIDS
○ clopidogrel
○ SSRI’s Drugs causing thrombocytopenia
○ alcohol
○ antibiotics – cephalosporins , nitrofurantoin , penicillins ,sulfonamides
○ quinine
○ propranolol
○ thiazide diuretics Anticoagulants
○ Warfarin
○ Heparins
○ NOACS

Investigations-Full blood count
○ low Hb may suggest that bruising is long standing or associated with bleeding elsewhere for eg GI tract
○ isolated low platelet count suggests thrombocytopenia as the likely cause
○ abnormal total and differential WCC + low platelets –> bone marrow disorder Blood film
○ identify morphological abnormalities in blood cells
○ platelet – shape and colour (can suggest inherited platelet disorder ) Clotting screen
○ PT , APTT and fibrinogen
○ can suggest inherited or acquired coagulation disorder INR in people taking warfarin Kidney and liver function tests TSH Urine dipstick test
○ non visible haematuria may suggest and underlying bleeding disorder or vasculitis Special tests -Von Willerbrand’s disease- VWF :Ag , VWF : Rco , FVIII Platelet function tests Coagulation factor assay Mixing studies Inhibitor assays Urea clot stability or euglobulin clot lysis time Alpha 2-Antiplasmin level and PAI-1 activity Reptilase time

Referral-Admit if significant active bleeding Refer children and young people for leukaemia if they have
○ unexplained petechiae or
○ hepatosplenomegaly or
○ FBC suggests leukaemia
 Children suspected Neuroblastoma –> refer for appt within 48 hrs
○ periorbital bruising
○ palpable mass or
○ unexplained enlarged abdominal organ
 Refer all other adults if there is
○ a low platelet count
○ abnormal clotting screen
○ normal blood results but a bleeding disorder is still suspected
○ positive family history ( especially ♀ with menorrhagia )

PT measures factors of the extrinsic 
& common pathways – eg factor VII 
deficiency and Vit K deficiency will ↑ PT
 PTT measures intrinsic & common
 pathways eg factor VIII and 
IX deficiency will ↑ PTT

LINKS AND RESOURCES

PATIENT INFORMATION

Patient info on why do some people bruise easily https://patient.info/news-and-features/why-some-people-bruise-so-easily

NHS -What are bruises https://www.nhs.uk/common-health-questions/accidents-first-aid-and-treatments/what-are-bruises/

How to differentiate bruising ( other causes ) from bruising of Leukaemia for patients from Luekaemia Care https://www.leukaemiacare.org.uk/support-and-information/latest-from-leukaemia-care/blog/spotting-the-difference-bruising-in-leukaemia-vs-ordinary-bruising/

Should you be worried about bruising easily from health US News Com https://health.usnews.com/wellness/articles/2016-06-13/should-you-be-worried-about-bruising-easily

INFORMATION FOR HEALTHCARE PROFESSIONALS

Senile purpura a review from Dermatology Advisor https://www.dermatologyadvisor.com/home/decision-support-in-medicine/dermatology/actinic-purpura/

Clotting Screen tests- what are they and what do they test ? http://www.pathology.leedsth.nhs.uk/pathology/ClinicalInfo/Haematology/ClottingScreen.aspx

Understand the blood coagulation process http://www.rnceus.com/coag/coagframe.html

 

References

  1. Valente MJ, Abramson N. Easy bruisability. South Med J. 2006;99(4):366‐370.  doi:10.1097/01.smj.0000209237.73616.33 https://pubmed.ncbi.nlm.nih.gov/16634245/
  2. Investigating easy bruising in an adult BMJ 2017 ; 356: j251
  3. Investigating easy bruising in a child BMJ 2010 ;341 ; c4565
  4. Clinical Evaluation of Bleeding and Bruising in Primary Care Am Fam Physician .2016 Feb 15;93 (4):279-286
  5. Bruising , Petechiae and Other Skin Changes Haematology : Basic Principles and Practice Hayward , Catherine P.M
  6. CKS NHS Bruising https://cks.nice.org.uk/bruising
  7. Bleeding and Bruising : A Diagnostic Work-up Am Fam Physician .2008 Apr 15;77 (8) : 1117-1124
  8. Ward, Michelle Gk et al. “The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective.” Paediatrics & child health vol. 18,8 (2013): 433-42. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3887084/
  9. Rydz N, James PD. Why is my patient bleeding or bruising?. Hematol Oncol Clin North Am. 2012;26(2):321‐viii. doi:10.1016/j.hoc.2012.01.002 https://pubmed.ncbi.nlm.nih.gov/22463830/
  10. Clinical Approach to the Patient With Bleeding or Bruising Catherine P.M.Hayward Hematology : Basic Principles and Practice , Chapter 130 . 1847-1856.e1

 

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