Patient will present as → a 50-year-old male who is scheduled to undergo an elective inguinal hernia repair. He has noted pain in the hernia, which is reducible, for the past year. His past history is significant for hypercholesterolemia and mild hypertension. He has had no prior surgery. He does not smoke and only drinks occasionally. Family history is positive for coronary artery disease. He takes aspirin and a statin. He takes no herbal remedies. On further questioning, he reports a history of excessive bleeding when he had a wisdom tooth extracted 20 years ago. Otherwise, he has no significant medical history. On physical examination, he has no stigmata of portal hypertension or cirrhosis. Intraoperatively, the patient is noted to have diffuse oozing from all tissues in the operative field. Despite attempts at complete hemostasis, the patient develops a postoperative hematoma which requires evacuation on postoperative day 2. Laboratory values include a normal chemistry panel, normal hemoglobin and hematocrit, a platelet count of 250,000 (normal 140,000–450,000), INR of 1.0, and a prolonged PTT of 45. (Von Willebrand disease)
HIT, ITP, TTP, Hemolytic Uremic Syndrome, Hemophilia, DIC, and Von Willebrand disease
Easy bruising can be defined as bruising without a history of trauma or bruising after minor trauma that would not have caused bruising in the past.
- Differentiating between bruising that might be considered normal versus clinically significant is challenging, given that there may not be specific symptoms and signs.
Medications — Drug-related bruising is most often related to NSAIDS, anticoagulant medications, antiplatelet agents, and glucocorticoids. Other commonly used agents that can predispose to bleeding include antidepressants (eg, fluoxetine, sertraline, paroxetine) and antibiotics (eg, penicillins, cephalosporins).
Nutrition
- Protein malnutrition - more common in less developed countries
- Vitamin C deficiency - in severely malnourished individuals, including institutionalized, chronically ill patients and those with alcohol abuse.
- Vitamin K deficiency - those with bacterial overgrowth, celiac disease, chronic pancreatitis, inflammatory bowel disease, and alcohol abuse.
Family history
- Only males affected suggests an X-linked disorder such as factor VIII or factor IX deficiency.
- Both males and females affected equally suggest an autosomal disorder such as von Willebrand factor deficiency, which is the most common congenital disorder of hemostasis. The less common disorders, such as inherited factor V and factor XI deficiencies, have a similar autosomal inheritance pattern.
Petechiae are the smallest bleeding lesions (pinhead in size) and suggest problems with platelet number or function.
Purpura can be seen in a variety of bleeding disorders, including thrombocytopenia and coagulation cascade disorders. Palpable purpura can be seen in vasculitic processes such as immunoglobulin A (IgA) vasculitis (Henoch-Schönlein purpura).
- Lymphadenopathy may indicate infection, connective tissue disease, or lymphoid malignancy.
- Hepatosplenomegaly may indicate systemic disease or chronic liver disease.
- Hypermobile joints or skin hyperelasticity can be seen with Ehlers-Danlos syndrome.
- Mitral valve prolapse and joint laxity are commonly seen in patients with Marfan syndrome.
What is the Differential Diagnosis of Bleeding in the Postoperative Setting?
- Surgical bleeding: Bleeding from a major artery or vein that was missed during surgery must be ruled out first, especially in the immediate postoperative period
- Medications: Inquire about aspirin, clopidogrel, heparin, warfarin, or any other antiplatelet or anticoagulant medication
- Inherited coagulation disorders: Patients with von Willebrand disease may have a history of excessive bleeding after minor procedures or very heavy menses; hemophilia A and B usually present in childhood with spontaneous hemorrhage into joints (hemarthrosis)
- Liver disease: Reduced production of clotting factors
- Renal failure: Uremia impairs platelet function
- Disseminated intravascular coagulation (DIC): Seen with severe sepsis, malignancy, and childbirth complications; leads to bleeding and microthrombi; manifests with diffuse bleeding from wounds and surgical sites, hematemesis, digital cyanosis, renal insufficiency, and stroke
| Condition | PT | PTT | BT | Acquired/congenital | H&P |
| Acquired FVIIII Inhibitors | - | ↑ | - | Acquired | Occurs in postpartum, rheumatic disease, and malignancy; presents with purpura and soft tissue bleeding |
| Antiphospholipid syndrome (SLE)* | - | ↑ | - | Acquired | Young woman with malar rash, arthritis, photosensitivity, renal/cardiac symptoms, fevers, malaise, and recurrent pregnancy loss |
| Hemophilia A | - | ↑ | - | Congenital | Presents early in childhood with spontaneous bleeding in joints (hemarthroses) or life-threatening hemorrhage following minor trauma |
| Hemophilia B | - | ↑ | - | Congenital | Same as hemophilia A |
| Heparin | - | ↑ | - | Acquired | Postoperative prophylaxis for DVT and PE, decreases post-MI thrombus risk |
| Von Willebrand disease | - | ↑ | ↑ | Young woman with bleeding after minor surgical procedure or history of excessive menses |
Pre-operative testing: If the family history, patient history, and/or physical examination suggests the presence of a bleeding disorder, appropriate screening tests should be performed
- PT
- aPTT
- platelet count
Question 1 |
Hemophilia A Hint: Hemophilia A is a genetic disorder characterized by a deficiency in factor VIII. It typically presents with prolonged aPTT and normal PT. This does not align with the patient's laboratory findings. | |
Vitamin K deficiency | |
Von Willebrand disease Hint: Von Willebrand disease is a common inherited bleeding disorder that typically presents with a prolonged bleeding time due to a qualitative or quantitative deficiency of von Willebrand factor. It usually does not cause isolated prolongation of PT. | |
Disseminated intravascular coagulation (DIC) Hint: DIC is a secondary condition characterized by systemic activation of blood coagulation, which results in the generation and deposition of fibrin, leading to microvascular thrombi in various organs and contributing to multiple organ dysfunction syndrome. It typically presents with prolonged PT and aPTT, thrombocytopenia, and elevated D-dimer levels, which is not consistent with this patient's presentation. | |
Chronic liver disease Hint: Chronic liver disease can lead to a deficiency in the production of clotting factors, resulting in prolonged PT and aPTT. However, in the absence of other clinical signs of liver disease (such as jaundice, ascites, or spider angiomas) and with normal aPTT, this is less likely. |