Bleeding (Excessive)

Bleeding (Excessive)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

• Bleeding occurring spontaneously without injury, or bleeding that does not stop (with direct pressure) is abnormal.

Abnormal bleeding can be classified into the following groups:

1. Coagulation factor disorders
2. Platelet disorders
3. Vascular disorders

Differential Diagnosis

In alphabetical order.

• Arteriovenous malformation
• Bernard-Soulier Syndrome
• Capillary wall abnormalities
• Disseminated intravascular coagulation (DIC)
• Drugs:

  • NSAIDs (nonsteriodal anti-inflammatory drugs)
  • Aspirin
  • Warfarin
  • Streptokinase
  • Beta-lactamase antibiotics
  • Dextran
  • Urokinase
  • Moxalactam
  • Clopidogrel
  • Eptifibatide
  • Abciximab
  • Tirofiban
  • TNK
  • tPA
  • rPA
  • Heparin
  • Fondaparinux
  • Enoxaparin

• Ehlers-Danlos Syndrome
• Glanzmann's Syndrome
• Hemolytic Uremic Syndrome and Thrombotic Thrombocytopenic Purpura (HUS-TTP)
• Hemophilia
• Heparin-Induced Thrombocytopenia
• Hereditary hemorrhagic telangiectasia
• HIV
• Immune Thrombocytopenic Purpura (ITP)
• Isolated factor deficiency
• Leukemia
• Liver disease
• Myelodysplasia
• Pancytopenia
• Schönlein-Henoch Purpura (HSP)
• Senile purpura
• Severe vitamin K deficiency
• Uremia
• Von Willebrand's Disease

Diagnosis

History and Symptoms

• Complete history

  • Family history
  • Minor trauma bleeding
  • Tooth extractions
  • Postsurgical bleeding
  • Medications
  • Menorrhagia

Physical Examination

• Complete physical examination including rectal exam and joint exam (hemarthrosis)

Laboratory Findings

• Complete blood count (CBC) with peripheral smear
• Partial thromboplastin time (PTT)
• Thrombin time
• Bleeding time
• Urinalysis
• Platelet count
• Prothrombin time / international normalized ratio (PT / INR)

Other Diagnostic Studies

• Stool guaiac testing
• Bone marrow aspiration
• Specific factor assays
• Platelet adhesion and aggregation testing
• Urea clot lysis test
• Fibrinogen assay
• Mixing studies

Treatment

• Treatment of underlying disease processes
• Remove offending drugs
• Transfusion and hemostasis
• Rapid IV hydration
• Supplemental oxygen
• Administration of fresh frozen plasma (DIC and liver disease)
• Administration of cyroprecipitate (uremia, DIC, von Willebrand's disease and hemophilia)
• Intravenous immunoglobulin (IVIG) for patients with ITP in emergency situations
• Factor VIII concentrate (von Willebrand's disease and hemophilia)

Acute Pharmacotherapies

• Desmopressin (DDAVP) for uremia, von Willebrand's and hemophilia
• Parenteral vitamin K (vitamin K deficiency)
• Corticosteroids (ITP, HSP)
• Tranexamic acid (liver disease)

Surgery and Device Based Therapy

• Splenectomy (ITP)

Acknowledgements

The content on this page was first contributed by Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3] Template:Hematology Template:SIB

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