Factors that suggest the presence of a systemic bleeding defect include:
• spontaneous haemorrhage
• severe or recurrent haemorrhagic episodes
• bleeding from multiple sites
• bleeding out of proportion to the degree of trauma
If a bleeding diathesis is suspected it is essential to determine whether local pathology is contributing to the blood loss, e.g. postoperative bleeding, postpartum bleeding, gastrointestinal haemorrhage.
• Platelet abnormalities present as early bleeding following trauma.
• Coagulation factor deficiencies present with delayed bleeding after initial haemostasis is achieved by normal platelets.
• A normal response to previous coagulation stresses, e.g. dental extraction, circumcision or pregnancy, indicates an acquired problem.
• If acquired, look for evidence of drugs, malignancy and liver disease.
• A diagnostic strategy is outlined in Table 35.2 .
Table 35.2 Purpura: diagnostic strategy model
Q. Probability diagnosis
Simple purpura (easy bruising syndrome) A Senile purpura . Corticosteroid-induced purpura Anaphylactoid purpura (Henoch-Schonlein)
Q. Serious disorders not to be missed
• myeloma Aplastic anaemia Myelofibrosis
A. Severe infections A. • septicaemia
• meningococcal infection
Disseminated intravascular coagulation Thrombocytopenic purpura
Q. Pitfalls (often missed)
von Willebrand's disease
Connective tissue disorders, e.g. SLE, RA
Trauma, e.g. domestic violence, child abuse
• hereditary telangiectasia (Osler-Weber-Rendu syndrome)
• Ehlers-Danlos syndrome
• Fanconi syndrome Q. The masquerades
• quinine/quinidine A. • thiazide diuretics
• oral anticoagulants Anaemia
• aplastic anaemia Q. Psychogenic factors A. Factitial purpura
A positive family history can be a positive pointer to the diagnosis:
• sex-linked recessive pattern o haemophilia A or B
• autosomal dominant pattern o von Willebrand's disease o dysfibrinogenaemias
• autosomal recessive pattern o deficiency coagulation factors V, VII and X
Enquire whether the patient has noticed blood in the urine or stools and whether menorrhagia is present in women. A checklist for a bleeding history is presented in Table 35.3 . The actual size and frequency of the bruises should be recorded where possible and if none are present at the time of the consultation the patient should return if any bruises reappear.
Table 35.3 Checklist for a bleeding history
• Skin bruising
• Domestic violence
• Tooth extraction
• Other operations
• Rectal bleeding
• Family history
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