Bruising and bleeding

My pa is one mask of brooses both blue and green.

Charles Dickens (1812-1870) Nicholas Nickleby

Many patients present with the complaint that they bruise easily but only a minority turn out to have an underlying blood disorder. Purpura is bleeding into the skin or mucous membranes, appearing as multiple small haemorrhages that do not blanch on pressure. Smaller purpuric lesions that are 2 mm or less in diameter (pinhead size) are termed petechiae while larger purpuric lesions are called ecchymoses (Fig 35.1).

Bruises are large areas of bleeding that are a result of subcutaneous bleeding. If bruising is abnormal and out of proportion to the offending trauma then a disturbance of coagulation is suggested. Differential diagnosis

'Palpable purpura' due to an underlying systemic vasculitis is an important differential problem. The petechiae are raised so finger palpation is important. The cause is an underlying vasculitis affecting small vessels, e.g. polyarteritis nodosa.

The decision to investigate is difficult because decisions have to be made about which patients warrant investigation and whether the haemostatic defect is due to local or systemic pathology. 1 The ability to identify a bleeding disorder is important because of implications for surgery, pregnancy, medication and genetic counselling.

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