Bleeding (Excessive)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

## Overview

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Bleeding occurring spontaneously without injury, or bleeding that does not stop (with direct pressure) is abnormal.

## Classification

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Abnormal bleeding can be classified into the following groups:

1. Coagulation factor disorders
2. Platelet disorders
3. Vascular disorders

## Causes

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In alphabetical order. [1] [2]

* Arteriovenous malformation
* Bernard-Soulier Syndrome
* Capillary wall abnormalities
* Disseminated intravascular coagulation (DIC)
* Drugs:

* NSAIDs (nonsteriodal anti-inflammatory drugs)
* Aspirin
* Warfarin
* Streptokinase
* Beta-lactamase antibiotics
* Dextran
* Urokinase
* Moxalactam
* Clopidogrel
* Eptifibatide
* Abciximab
* Tirofiban
* TNK
* tPA
* rPA
* Heparin
* Fondaparinux
* Enoxaparin
* Ehlers-Danlos Syndrome
* Glanzmann's Syndrome
* Hemolytic Uremic Syndrome and Thrombotic Thrombocytopenic Purpura (HUS-TTP)
* Hemophilia
* Heparin-Induced Thrombocytopenia
* Hereditary hemorrhagic telangiectasia
* HIV
* Immune Thrombocytopenic Purpura (ITP)
* Isolated factor deficiency
* Leukemia
* Liver disease
* Myelodysplasia
* Pancytopenia
* Schönlein-Henoch Purpura (HSP)
* Senile purpura
* Severe vitamin K deficiency
* Uremia
* Von Willebrand's Disease

## Diagnosis

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### History and Symptoms

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* Complete history

* Family history
* Minor trauma bleeding
* Tooth extractions
* Postsurgical bleeding
* Medications
* Menorrhagia

### Physical Examination

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* Complete physical examination including rectal exam and joint exam (hemarthrosis)

### Laboratory Findings

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* Complete blood count (CBC) with peripheral smear
* Partial thromboplastin time (PTT)
* Thrombin time
* Bleeding time
* Urinalysis
* Platelet count
* Prothrombin time / international normalized ratio (PT / INR)

### Other Diagnostic Studies

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* Stool guaiac testing
* Bone marrow aspiration
* Specific factor assays
* Platelet adhesion and aggregation testing
* Urea clot lysis test
* Fibrinogen assay
* Mixing studies

## Treatment

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* Treatment of underlying disease processes
* Remove offending drugs
* Transfusion and hemostasis
* Rapid IV hydration
* Supplemental oxygen
* Administration of fresh frozen plasma (DIC and liver disease)
* Administration of cyroprecipitate (uremia, DIC, von Willebrand's disease and hemophilia)
* Intravenous immunoglobulin (IVIG) for patients with ITP in emergency situations
* Factor VIII concentrate (von Willebrand's disease and hemophilia)

### Acute Pharmacotherapies

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* Desmopressin (DDAVP) for uremia, von Willebrand's and hemophilia
* Parenteral vitamin K (vitamin K deficiency)
* Corticosteroids (ITP, HSP)
* Tranexamic acid (liver disease)

#### Contraindicated medications

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Active pathological bleeding is considered an absolute contraindication to the use of the following medications:

* Dabigatran
* Dalteparin
* Desirudin

### Surgery and Device Based Therapy

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* Splenectomy (ITP)

## References

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1. ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
2. ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X

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