Bleeding (Excessive)

Overview
Bleeding occurring spontaneously without injury, or bleeding that does not stop (with direct pressure) is abnormal. Abnormal bleeding can be classified into the following groups:
 * 1) Coagulation factor disorders
 * 2) Platelet disorders
 * 3) Vascular disorders

Differential Diagnosis
In alphabetical order.


 * 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

History and Symptoms

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

Physical Examination

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

Laboratory Findings

 * 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

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

Treatment

 * 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

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

Surgery and Device Based Therapy

 * Splenectomy (ITP)

Acknowledgements
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