Bleeding

Bleeding

Bleeding	Assess whether bleeding is spontaneous, or inappropriate and/or excessive in relation to trauma. Note site and nature of bleeding; presence and duration of previous history of surgical, dental, joint, menstrual, mucosal, and skin bleeding; presence of underlying disorder, or use of drugs associated with risk of bleeding. Laboratory testing if indicated; see Figure 1 . See also Bruising , Purpura .
Acquired bleeding disorders	Initially - FBC , blood film , platelet count . Additional tests as indicated by the clinical context; see below.
Advanced and/or metastatic carcinoma	See under Carcinoma .
Blood transfusion related DIC	See under Blood transfusion .
Drug-related bleeding
Anticoagulant therapy	See Anticoagulant monitoring .
Fibrinolytic therapy	See Thrombolytic therapy .
Aspirin, other NSAID	Predictable abnormality of bleeding time and platelet aggregation; these tests do not predict the risk of bleeding and are not indicated.
Thrombocytopenia
Liver disease	See Bleeding under Cirrhosis - consequences.
Multiple myeloma
Myeloproliferative disorders esp
Essential Thrombocythaemia Myelofibrosis
Neonatal bleeding
Obstetric (peripartum) bleeding	See under Pregnancy .
Paraproteinaemia
Renal failure	See Bleeding under Renal failure - chronic (complications).
Rodenticide poisoning	See under Poisoning .
SLE
Thrombocytopenia
Inherited bleeding disorders	There is usually a personal and/or family history of bleeding. Mild disorders may present as surgical or dental bleeding in the adult. Initially - FBC , platelet count , blood film ; PT , APTT . Normal results do not exclude the possibility of a clinically significant inherited bleeding disorder and further investigation should be determined on the basis of the history. The bleeding time has little place in this initial assessment; consult pathologist. Further tests as indicated from the initial results, and as appropriate to the history and the degree of clinical suspicion. See Figure 1 .
von Willebrands disease
Haemophilia A	See under Haemophilia .
Haemophilia B	See under Haemophilia .
Factor XI deficiency	Coagulation factors (XI) assay.
Factor XII deficiency	Coagulation factors (XII) assay; this deficiency is not associated with an increased risk of bleeding.
Factor XIII deficiency	Factor XIII screening test; consult pathologist.
Hypofibrinogenaemia/ afibrinogenaemia	Thrombin time , fibrinogen assay .
Dysfibrinogenaemia	Thrombin time , reptilase time ; consult pathologist.
Other inherited coagulation disorders	Rare; consult pathologist.
Inherited disorders of platelet function	A normal bleeding time does not exclude a clinically significant disorder of platelet function.
Release disorders eg	Platelet aggregation/release studies. For definitive platelet membrane, granule, and prostaglandin studies - consult pathologist.
Storage pool disease
Thrombasthenia
Bernard Soulier syndrome
Hereditary haemorrhagic telangiectasia	Clinical diagnosis. Mucocutaneous telangiectases with recurrent bleeding from mucosal surfaces. See also Telangiectases .
Collagen disorders	The bleeding time may be prolonged.