Bruising in the elderly is a common presentation. This chart on A4Medicine can be helpful in data gathering and plan further investigations based on clinical suspicion. The clinician should consider Vitamin C deficiency as an easily treatable cause of bruising.Perio-orbital bruising can be a presentation of Nueroblastoma in children and should alert the clinician to examine the child further. A list of possible first line investigations is also available. Senile purpura is a common cause of bruising in the elderly.
Common problem Bruise – haematoma which forms due to bleeding under intact skin in s/c tissue due to vascular damage or injury Damage that causes bleeding can be ○ trauma external to vessel ○ internal to the vessel ○ vessel itself Colour changes Red discoloration → purple → brownish yellow Usually disappears within 2-3 weeks A detailed history often provides sufficient information Bruising is reported ↑ frequently by women than men
History-What does the patient mean Circumstances -spontaneous or following trauma ? dental procedures Age of manifestation General overall health ○ past medical history ○ past surgical history- all operations , dental extractions etc Type of bleeding ie epistaxis , menorrhagia or hematomas Any petechiae or purple patches ( purpura ) with bruises Nutritional status Alcohol use or risk factors for chronic liver disease Prescribed and OTC drug history Family history – particularly ○ bleeding disorders –> haemophilia ( rare 1 in 5000 ) , von Willerbrand’s disease or a platelet disorder ○ tendency to bruise or bleed easily or spontaneously ○ menorrhagia or post-partum bleeding – may indicated non sex linked dis as von Willerbrands or factor XI deficiency ○ consanguinity ↑ risk autosomal recessively inherited disorders as factor X deficiency ○ Hereditaey haemorrhagic telangiectasia , Ehler-Danlos syndrome or osteogenesis imperfecta Colour of bruising not a reliable indicator of age
Examination-Location and pattern of bruising ○ distribution , number , site , shape ○ presence of petechiae and ecchymoses ○ dependent areas – thrombocytopenia or stasis factors ○ atypical areas eg on trunk ( consider bleeding disorder or NAI _ ○ patterned bruising eg hand print or belt ○ distribution for eg- only on arms and legs ( trauma or changes in skin and s/c tissue ) ○ location – dorsum of hands , extensor surface of the forearms and the shins → senile purpura Signs of malnutrition ( brittle hairs , nails , cachexia ) Joints ( haemarthroses ) Abdomen ( signs of chronic liver disease ) Oral cavity ( gum hyperplasia , periodantal inflammation -Vit C deficiency ) Lymphadenopathy
Causes- Trauma Consider accidental and non-accidental injuries Cupping or coining may contribute towards it Vascular- Senile purpura ( common ) Senile purpura ( easy bruising syndrome ) young ♀ Hereditary haemorrhagic telangiectasia ( HHT – rare ) Ehler-Danlos syndrome Osteogenesis imperfecta Vitamin C deficiency ( Scurvy ) Platelet disorders -Acute idiopathic thrombocytopenic purpura ( ITP ) Chronic ITP Henoch-Schlonlein purpura ( HSP ) Aplastic anaemia Malignancy End stage CKD Liver disease Coagulation -May be inherited or acquired Negative family hx → does not r/o genetically inherited disorder Haemophilia A ( Factor VIII deficiency ) and Haemophilia B ( factor IX deficiecny ) Liver disease Vitamin K deficiency Von Willerbrand’s disease- most common inherited coagulation disorder prevalence 1-2 % gen population Amyloidosis Drugs-Corticosteroids Platelet inhibitors ○ aspirin ○ NSAIDS ○ clopidogrel ○ SSRI’s Drugs causing thrombocytopenia ○ alcohol ○ antibiotics – cephalosporins , nitrofurantoin , penicillins ,sulfonamides ○ quinine ○ propranolol ○ thiazide diuretics Anticoagulants ○ Warfarin ○ Heparins ○ NOACS
Investigations-Full blood count ○ low Hb may suggest that bruising is long standing or associated with bleeding elsewhere for eg GI tract ○ isolated low platelet count suggests thrombocytopenia as the likely cause ○ abnormal total and differential WCC + low platelets –> bone marrow disorder Blood film ○ identify morphological abnormalities in blood cells ○ platelet – shape and colour (can suggest inherited platelet disorder ) Clotting screen ○ PT , APTT and fibrinogen ○ can suggest inherited or acquired coagulation disorder INR in people taking warfarin Kidney and liver function tests TSH Urine dipstick test ○ non visible haematuria may suggest and underlying bleeding disorder or vasculitis Special tests -Von Willerbrand’s disease- VWF :Ag , VWF : Rco , FVIII Platelet function tests Coagulation factor assay Mixing studies Inhibitor assays Urea clot stability or euglobulin clot lysis time Alpha 2-Antiplasmin level and PAI-1 activity Reptilase time
Referral-Admit if significant active bleeding Refer children and young people for leukaemia if they have ○ unexplained petechiae or ○ hepatosplenomegaly or ○ FBC suggests leukaemia Children suspected Neuroblastoma –> refer for appt within 48 hrs ○ periorbital bruising ○ palpable mass or ○ unexplained enlarged abdominal organ Refer all other adults if there is ○ a low platelet count ○ abnormal clotting screen ○ normal blood results but a bleeding disorder is still suspected ○ positive family history ( especially ♀ with menorrhagia )
PT measures factors of the extrinsic & common pathways – eg factor VII deficiency and Vit K deficiency will ↑ PT PTT measures intrinsic & common pathways eg factor VIII and IX deficiency will ↑ PTT