HNY Policy and Pathway Repository - North Yorkshire

(Also relevant for other bleeding symptoms)

Easy bruising is a relatively common symptom, especially in females or the elderly. In a published survey of 500 healthy individuals, 18% felt they bruised easily.

Easy bruising as a solitary symptom is unlikely to be significant, however suspicion is higher when accompanied by other haemorrhagic problems (e.g. epistaxis, gum bleeding, menorrhagia or bleeding at previous childbirth, surgery or dental extraction) or if there is a family history of a bleeding disorder.

A life-long history of a bleeding tendency may point towards an inherited disorder while a more recent history suggests an acquired cause.

None provided

Differential diagnosis:

• Acquired:
  • Trauma, often arms & legs but can be atypical if non-accidental injury
  • Low platelets, especially if <50 x10 9 /l, multiple causes see above.
  • Abnormal platelet function e.g. uraemia, liver disease, NSAIDs, clopidogrel, anti-depressants (SSRI), anticonvulsants.
  • Abnormal coagulation e.g. liver disease, anticoagulants.
  • Vascular defect e.g. amyloid, corticosteroids, scurvy, senile purpura (usually dorsum of hands and extensor surfaces of forearms).
  • Autoimmune disease e.g. thyroid disease.
• Inherited:
  • Vascular disorders, all rare and generally associated with other features, e.g. Marfan syndrome, Ehlers-Danlos syndrome, hereditary haemorrhagic telangiectasia.
  • Inherited platelet disorders, rare and generally mild.
  • Inherited coagulation factor deficiency, e.g. all rare except Von Willebrand disease. Haemophilia A & B can present in later life if mild (a third have no family history).

Easy bruising or other haemorrhagic symptoms are very subjective. An anxious patient may worry about minor symptoms while a patient with a true bleeding disorder may disregard significant symptoms as being normal for their experience. Patients with bleeding disorders often have multiple haemorrhagic symptoms or symptoms which have required medical intervention.

Examination

Should look for current bruises (size, distribution), petechiae (very suggestive of vascular or platelet disorder) or mucosal bleeding. Also check for lymphadenopathy, hepatomegaly or splenomegaly.

Baseline investigations

Therefore include: FBC (NICE suggest urgent <48hr), blood film, coagulation screen (inc. PT, APTT and fibrinogen), U+E, liver function and thyroid function. NICE also suggest urine dipstick for haematuria.

Referral:

Patients with significant or multiple symptoms or abnormal baseline investigations should be referred to Haematology.

References:

NICE Clinical Knowledge Summary. Bruising (March 2021). https://cks.nice.org.uk/bruising 

• South Tees Hospitals