APPROACH TO

BLEEDING
DISORDER

DR.SUALEHA AHMED
SENIOR REGISTRAR
MEDICAL UNIT 2
Hemostasis
Hemostasis is the process by which bleeding is arrested after injury to
blood vessels. It is a delicate multiphase process that involves
interactions between the blood vessels, platelets and coagulation
factors.
Primary hemostasis
weak platelet plug formation
Disorders of primary hemostasis are mostly due to platelet
abnormalities e.g
• TTP
• ITP
• HUS
Secondary hemostasis
stabilizes the weak platelet plug via coagulation cascde
Disorders of secondary hemostasis are due to factors abnormality e.g
• Hemophilia A
• hemophilia B
• vWD
• vit K defficiency
BLEEDING DISORDER
A defect in any phases of coagulation can result in a bleeding problem
which may be inherited or acquired
Approach To Bleeding Disorder
• History
• Physical exam
• Labs\investigation
• DDx
• Management
HISTORY
Type and Sites of bleeding
• Whether it involves the skin and mucous membranes i.e. petechiae,
purpura, bruises, epistaxis, gingival bleeding, menorrhagia and/or
hematuria which would suggest a platelet and/or vascular
abnormality.
• Bleeding into deep tissue, joints and muscles suggest a coagulation
factor defect.
• Bleeding is spontaneous or follows trauma must also be asked.
Usually a history of easy bruising or bleeding excessively after injury,
childhood history of epistaxis, umbilical stump bleeding, bleeding after
circumcision would suggest inherited bleeding disorders.
• Duration
This would indicate whether symptoms have been lifelong (since
childhood) or of recent onset.
• Drug history is of extreme importance since a wide variety of drugs
affect hemostasis.
• Family history
Any family history of abnormal bleeding in both parents, maternal
grandparents, aunts, uncles, and siblings as well as any history of
consanguineous marriage (or among relatives) should be taken.
Questions with the four “W's
• Who: who is the patient, sex, age and family history?

• When: when did the bleeding occur, i.e. onset of bleeding? Is it

related to drug ingestion or any underlying disorder? Did it develop
after surgery or trauma?

• Where : sites of bleeding, skin, muscle etc.

• What: description of the type of bleeding.

PHYSICAL EXAMINATION
• Mucocutaneous bleeding (e.g., petechiae, epistaxis, gingival bleeding,
gastrointestinal or genitourinary bleeding) suggests a platelet
disorder.
• Petechiae are pinpoint hemorrhages (< 2 mm) in the skin, and
purpura (0.2-1 cm) and ecchymoses are larger hemorrhages
Petechiae
Purpura
Ecchymosis
• Hemophilia or other congenital bleeding disorders should be
considered in patients with spontaneous hemarthroses, muscle
hemorrhages, or retroperitoneal bleeding
• Hepatomegaly suggests liver failure, whereas splenomegaly may
suggest underlying malignancy
Investigations
• CBC:
Degree of anemia, platelete count, diffrential leukocyte count
(hematopoetic disorders)
• Bleeding time (BT)
An abnormal bleeding time alone suggests a platelet aggregation defect
that is most likely due to medication.
• Platelet count
If the platelet count alone is low, the cause is usually peripheral
destruction of platelets, immunothrombocytopenia, or an abnormality of
bone marrow production.
• Activated partial thromboplastin time (aPTT)
When the aPTT is the only abnormal test and the patient has a definite
history of bleeding, one of the hemophiliac states is present.
• Prothrombin time (PT)
An abnormal PT, with or without an abnormal aPTT but with normal
results in the other three tests, indicates an abnormal reduction in the
vitamin K-dependent clotting factors (II, VII, IX, X) or factor V.
• Thrombin time (TT)
When the TT is abnormal, disseminated intravascular coagulation, the
presence of plasma heparin, or a hepatopathy should be suspected.
• LFTs
• RFTs
DDx
• Thrombocytopenia
• ITP
• HUS
• Hemophilia A (VIII)
• Hemophilia B (IX)
• vWD
• DIC
• Liver disease
• vit K deficiency
• Drug induced bleeding
THROMBOCYTOPENIA
Might occur as a result of a bone marrow disorder such as leukemia or
an immune system problem or it can be a side effect of taking certain
medications
Presntation
• Bleed spontaneously in your eyes, gums, or bladder or bleed too
much when you're injured
Management
• Blood transfusion
• Splenectomy
• Steroids (ITP)
Hemophilia A (VIII)
X-linked, recessive inherited or acquired genetic mutation that results
in dysfunction or deficiency of factor VIII or by an acquired inhibitor
that binds factor VIII.
Presentation
• Hemorrhage disproportionate to trauma
• History of spontaneous hemorrhage
• Bleeding disorders in the family
Management
• Transfusion
• Replacement Therapy (factor VIII)
Hemophilia B (IX)
Genetic disorder caused by missing or defective factor IX.
X-linked recessive trait or spontaneous mutation.
Presentation
• Joint bleeding is the most common symptom of severe hemophilia B
• Easy, frequent and severe bruising and muscle bleeds.
• Less commonly nosebleeds, gastrointestinal and central nervous
system bleeding.
Management
• Replacement therapy
vWD
Inherited abnormal gene that controls von Willebrand factor
Presentation
• Nosebleeds and hematomas.
• Prolonged bleeding from trivial wounds.
• Oral cavity bleeding.
• Excessive menstrual bleeding.
Management
• Desmopressin
• Exogenous VWF concentrates
HUS
Caused by infection with certain strains of E. coli bacteria, which first affect
the digestive tract. The initial signs and symptoms of this form of HUS may
include: Diarrhea, which is often bloody.
Presentation
• Thrombocytopenia
• Bloody diarrhea
• Altered mental status
• Renal dysfunction
• Fever
• MAHA
Management
• Plasma exchange with FFP
• Antibiotics
• Steroids
Medications that Cause Bleeding or
Bruising
MECHANISM OF ACTION DRUGS
• Coagulation inhibition Apixaban (Eliquis),* dabigatran (Pradaxa),* enoxaparin
(Lovenox),* heparin, rivaroxaban (Xarelto),* warfarin (Coumadin)*

• Collagen degradation Corticosteroids

• Platelet function inhibition Aspirin/nonsteroidal anti-inflammatory drugs,* clopidogrel

(Plavix),* fish oil, selective serotonin reuptake inhibitors
• Thrombocytopenia Alcohol, antibiotics (cephalosporins, linezolid [Zyvox],
nitrofurantoin, penicillin, rifampin, sulfonamides, vancomycin),
carbamazepine (Tegretol), quinine, thiazide diuretics,
valproic acid (Depakene)
DIC
Blood clots form throughout the body, blocking small blood vessels.
Cause is usually due to inflammation, infection, or cancer.
Presentation
• Manifests as petechiae and ecchymosis
• Blood loss from intravenous (IV) lines and catheters.
• In postoperative DIC, bleeding can occur in the vicinity of surgical sites
Management
• Correction of the cause
• Replacement of platelets
• Coagulation factors
• Fibrinogen
• Heparin( in patients with slowly evolving DIC)
 MCQS
• Q.NO.1 15years old boy spontanously developed hemarthroses of
Right knee joint. What could be most likely cause of bleeding in his
case?
• A. platelet abnormalities
• B. clotting factor abnormalities
• C. liver failure
• D. vit k deficiency
• E. Drug induced
 MCQS
• Q.NO.1. KEY : B
 MCQS
• Q.NO.2. Which of the following deficiency is likely to cause prolong
prothrombin time?
• A. clotting factor II
• B. Clotting factor VII
• C. clotting factor IX
• D. clotting factor X
• E. clotting factor XIII
 MCQS
• Q.NO.3 Mucocutaneous bleeding (e.g petechiae,epistaxis,gingival
bleeding, gastrointestinal bleeding or genitourinary bleeding)
suggests a
• A. clotting factor disorder
• B. Platelet disorder
• C. vitamin K deficiency
• D. liver failure
• E. drug induced
 MCQS
• Q.NO.3. KEY :B
 MCQS
• Q.NO.4 pinpoint hemorrhges (< 2mm) in the skin are
• A. purpura
• B. petechiae
• C. ecchymoses
• D. bruises
• E. b & c
 MCQS
• Q.no.4. key ; B
 MCQS
• Q.NO.5. For formation of fibrin from fibrinogen, following factor is
required
• A.prothrombin
• B.thrombin
• C. factor X
• D. factor IX
• E. factor XII
 MCQS
• Q.NO.5. KEY : B
 SEQ
• Q. A Young male presents in emergency department with complaints
of fever, bloody diarrhea and altered mental state.his CBC shows
anemia and thrombocytopenia with derranged renal function tests.
• 1. what is the probable diagnosis? (2)
• 2. underlying causative agent? (1.5)
• 3. which type of anemia you suspect in this case? (1.5)
 SEQ
• Key
• 1. HUS : hemolytic uremic syndrome
• 2. E.coli
• 3. microangiopathic hemolytic anemia
 OSPE
• Q. a 25 years old female presents in out patient department with
complaints of heavy menstural bleed along with recent history of
recurrent nosebleed and oral cavity bleeding. Her lab tests show
prolong bleeding time and prolong APTT
• 1. what is the probable diagnosis? (2.5)
• How will you manage it ? (2.5)
 OSPE
• Key
• 1. vonwillibrand disease
• 2. a, desmopressin
b, exogenous VWF concentrates