BLEEDING DISORDERS; A

CLINICAL APPROACH
PACES Station 5

Mamdouh L Dorrah
MRCP-UK London
Causes of bleeding disorders
• Vascular defects
a) Congenital; Osler-Weber-Rendu syndrome, Ehler-Danlos Syndrome, Pseudoxanthoma
elasticum.
b) Acquired; Senile Purpura – Steroid therapy – Scurvy – Henochschonlein Purpura – Infection.
• Platelet defects
a) Decreased platelet production
b) Increased platelet destruction
c) Non-functioning platelets.
• Coagulation defects
a) Congenital; Hemophilia – Von Willebrand disease.
b) Acquired; Anticoagulants – Liver disease – Malabsorption – DIC.
Approach; Introduction
In approaching a patient with a bleeding disorder, it is crucial to
determine the pattern of bleeding and the presence or absence of red
flags.
Identification of the pattern of bleeding is important to shortlist the
differential diagnoses.
Spotting the red flags is essential as a guidance for arrangement of a
proper management plan. The presence of red flags indicates the
necessity and urgency of immediate resuscitation.
Approach; pattern of bleeding
• Bleeding due to vascular and platelet defects results in bleeding into
skin and bleeding from mucus membranes.

• Bleeding due to vascular defects results in bleeding into joints and

muscles.
Approach, Red Flags
Immediate resuscitation is indicated in the presence of any of the
following red flags;
1. Dizziness – shock – coma.
2. Hypovolemia.
3. Postural hypotension
4. Oliguria.
5. CNS bleeding – Meningism – Neurological manifestations
Approach; History taking
History of the Presenting Complaint “HPC”
Same condition?
Family History Bleeding disorder?
• Bleeding pattern; Bruising? “ onset – course – Cancer?
duration – distribution” – Bleeding “ site –
frequency – aggravating factors – trauma” – Other Antiplatelet? –
sites of bleeding? “ GIT- GUT- URT-CNS”. Anticoagulants? Heparin? Social History
• Red flags; Dizziness- Shock – Coma – Postural Herbals?
hypotension – Oliguria – CNS bleeding “
• Other associations; Recent blood loss – Blood Impact
donation – Blood transfusion. Drug History
Concern
SLE? CTD? Platelet
Past Medical History disorder? Bleeding
disorder?
Approach; Clinical examination
Rash; Morphology - Distribution
Remember !
Spotting the red flags is essential as a guidance for
arrangement of a proper management plan. The presence of
Signs of Anemia red flags indicates the necessity and urgency of immediate
resuscitation.
Face & Mouth for signs of HHT Laboratory work up
• FBC.
• Blood film.
Abdomen for Organomegaly • PT.
• APTT.
Red Flags; • Fibrinogen and FDPs.
• Pulse & JVP for shock and • LFTs.
hypovolemia. • Viral hepatitis serology.
• CNS; Abbreviated mental score and • Autoimmune profile.
neurological examination. • HIV serology; obtain a verbal consent.
Anticoagulation; How to approach?
History
• Dose?
• Indication?
• Last INR?
Examination
• Bleeding? Bruising?
• Anemia? • Pulse.
• BP
• Yellow anticoagulant record
• CVS examination
book?
• Factors that have the potential to
cause INR instability? Alcohol –
New medication - Type of diet?
Thank you