How To Evaluate Bleeding Disorder

Spontaneous, or excessive post-traumatic (immediate or delayed) bleeding may be an indication of a localized pathological process or a disorder of the hemostatic process.

Accurate diagnosis and treatment of patients with bleeding requires some basic understanding of the pathophysiology of hemostasis. The process is divided into primary and secondary components

1.Primary hemostasis is formation of platelet plug at sites of injury and occurs within seconds of injury
2.Secondary hemostasis describes the coagulation system, which result in fibrin formation. It requires several minutes to complete. The fibrin strands strengthen the hemostatic platelet plug. This process is particularly important in bleeding originating from large vessels and in preventing recurrent bleeding hours or days after the initial injury

Bleeding disorders can thus be categorized into three groups:

1.disorders of platelet function or number
2.disorders of clotting factors
3.combination of the above

History And Physical Examination
The evaluation of the bleeding patient should primarily be focused on the following:

-Is the patient bleeding? Surrogate markers of bleeding (such as a declining hemoglobin) are often subject to misinterpretation. Hence deciding whether the patient is bleeding or not should not be solely based on a declining hemoglobin or sudden hypotension. Hemolysis or hemodilution represent other causes of a decline in hemoglobin
-If bleeding is suspected; identify the site and severity, duration of bleeding and clinical setting.
-Mucocutaneous bleeding suggests a platelet disorder. It includes petechiae, ecchymoses, epistaxis, and genitourinary and gastrointestinal bleeding.
-Bleeding into potential spaces (joints, fascial planes, retroperitoneum) suggests a coagulation factor deficiency.
-Bleeding from multiple sites in hospitalized patients can be seen with disseminated intravascular coagulation (DIC) or Thrombotic Thrombocytopenic Purpura (TTP).


A complete history should include the following elements
-A history of human immunodeficiency virus (HIV), liver or kidney disease, or malabsorption is often helpful
-A medication history with particular attention to anticoagulants, nonsteroidal anti-inflammatory drugs (NSAIDs), oral contraceptives, antibiotics, ethanol, and dietary vitamin K and vitamin C.
-The response to past hemostatic challenge such as trauma, tooth extraction, pregnancy, surgery, sports, and menstruation.
-A family history for bleeding disorders may be helpful for the assessment of pathologic bleeding
-The clinical setting of the bleeding patient
-Acute massive mucocutaneous bleeding in an individual previously without symptoms should suggest immune thrombocytopenic purpura (ITP).
-Massive bruising and oozing from multiple sites in otherwise asymptomatic individuals could suggest accidental warfarin ingestion, or acquired factor VIII inhibitors (particularly in older individuals).
-Postoperative bleeding at a surgical site is usually related to a local surgical problem.

Physical examination should focus on identifying signs of bleeding (petechiae, mucosal bleeding, soft tissue bleeding and ecchymoses) as well as signs of systemic disease.