Evaluation of the patient with a bleeding tendency

An apparent bleeding tendency is a common clinical problem, with presentation varying from acute unexpected bleeding during or immediately after surgery or dental extraction, to spontaneous unusual or excessive bruising, purpura, epistaxis, or a chronic haemorrhagic tendency. Long-standing bleeding symptoms suggest a lifelong condition, whereas recent-onset bleeding suggests an acquired disorder. If a bleeding disorder has been diagnosed and characterized in another family member, then the cause of bleeding may be easily identified, but the absence of a family history does not exclude a heritable disorder. The commonest cause of an acquired bleeding disorder is antithrombotic therapy. Investigations for bleeding disorder include full blood count and film (severe bleeding rarely occurs in the absence of trauma with a platelet count of more than 20 to 30 × 109/litre), prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen level, reptilase time (useful for determining if a prolonged APTT is due to heparin), individual factor assays, mixing studies (can indicate if prolongation of PT or APTT is likely due to a factor deficiency or an inhibitor), platelet function analysis, and (rarely) bleeding time. Aside from general supportive care, specific therapy can be given when a defined haemostatic abnormality is identified. Drugs that cause bleeding should be stopped. Overanticoagulation due to a vitamin K antagonist can be reversed with vitamin K and/or prothrombin complex concentrate; dabigatran and be reversed with idarucizumab; it will soon be possible to reverse factor Xa-inhibitors (e.g. with andexanet alfa). Vitamin K should also be given to critically ill patients and those with liver disease. Early and sufficient blood product support should be given to those with massive blood loss and/or dilutional coagulopathy.