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Sunday October 19, 2008

I bruise easily

Easy bruising needs to be evaluated carefully as some cases may have serious underlying problems.

A BRUISE or ecchymosis is caused by bleeding underneath the skin and leakage of red blood cells out of injured blood vessels. This is a common complaint and a good majority of them turn out to have nothing sinister or serious.

Nevertheless, easy bruising needs to be evaluated carefully because a few of these cases may have serious underlying disorders.

Some of the important factors for doctors to sort out whether this is something trivial or a serious problem include the duration of the symptom, local or generalised bruising (if there is bleeding from other sites) and accompanying symptoms such as fever, weight loss, joint pain and so on.

All patients with easy bruising need careful history and thorough physical examination followed by laboratory tests, which are guided by clinical impression.

Anatomy of a stable clot

The fear of patients presenting with easy bruising is the likelihood of a defect or defects in the clotting mechanism causing “excessive bleeding”. The formation of a stable clot would need:

1. An intact coagulation system with adequate coagulation factors.

2. Adequate platelet count with normal platelet function.

3. Normal blood vessels which constrict locally to decrease blood flow in time of injury.

Patients with low coagulation factors such as in liver dysfunctions can bruise/bleed excessively.

Patients with low platelet count (thrombocytopenia) can develop spontaneous bruising and similarly those with impaired platelet function can have bleeding problems.

Vascular or blood vessel abnormalities rarely cause significant bleeding.

Some patients can have multiple clotting or haemostatic failures such as in disseminated intravascular coagulation (DIC) where there is consumption of both clotting factors and platelets due to activation by procoagulants or substances that promote clotting.

A bruise is due to leakage of red blood cells into the underlying skin area.

History is essential

Easy bruising at different age groups can have some unique causes. For instance, the commonest cause of easy bruising in childhood in tropical countries like Malaysia is a condition called acquired platelet dysfunction with eosinophilia (APDE).

This is an interesting disorder (poorly documented by Western authors!) resulting from the overactive or hyperimmune response to parasitic infestations and the resultant immune complexes “coat” the platelets, causing defective platelet function and hence the bleeding tendency.

Amongst the elderly, easy bruising is fairly common. The so-called senile purpura is likely due to capillary fragility and weakened collagen tissue with ageing and is entirely innocuous.

Easy bruising is a far commoner complaint amongst females. If the bruises occur for the first time excessively over a short period, she needs to be evaluated urgently.

Patients who have bruises for years generally do not have blood clotting or serious blood disorders. A common problem is the “easy bruising syndrome”, which typically occurs in females of reproductive age. The underlying cause is unknown and has been linked to fragile blood vessels, antibody problems or hormonal disturbance. The laboratory tests on coagulation studies are typically normal. The bottom line is that there is no bleeding tendency even when they are challenged with surgical procedures/operations or when they sustain injuries.

Family history is important because some bleeding disorders are inherited, with the well known examples being haemophilia A (Factor VIII deficiency) and B (Factor IX deficiency) and Von Willebrand’s disease.

Drug history is crucial in clinical practice. Aspirin, non-steroidal anti-inflammatory drugs (NSAID), steroids and warfarin are capable of causing bleeding problems.

Some “health foods” such as ginseng, spirulina and gingko can result in bleeding due to their anti-platelet actions.

Circulating leukaemic cells.

Unexplained bruises in unusual locations such as around the eye or face should raise the possibility of domestic violence or abuse.

Past medical history of bleeding episodes are illuminating to the underlying cause. Patients who could go through surgical procedures such as dental extractions without bleeding problems are unlikely to have serious congenital bleeding disorders. Patients with liver disease, renal failure and bone marrow failure (e.g. aplasia or leukaemia) can have bleeding tendency.

Some of the more definitive symptoms indicative of serious disorder include bleeding from multiple sites, for instance nose bleed, gum bleed, gastrointestinal bleed with black stool or melaena, bleeding in the urine (haematuria) , menorrhagia (excessive menstrual bleed) or prolonged bleeding during or after surgery/tooth extraction.

Other symptoms such as persistent fever, painful joints and bone pain would need further evaluation.

Physical findings such as bleeding in the eyes and wet purpura in the mucous membranes are indicators of serious haemostatic or clotting failure. Severe pallor would indicate anaemia and hence the severity of the bleed.

Wet purpura in the buccal mucosa (mouth) is likely to be associated with severe thrombocytopenia.

Thrombocytopenia or platelet dysfunctions are associated with petechiel haemorrhage (small little bleeding spots) and mucosal bleeds such as gum or nose bleed.

Bleeding into joints and muscles are indicative of coagulation problems such as haemophilia or liver diseases. Acute leukaemic patients can present with pallor, enlarged lymph nodes, swollen gum and spleen. They would need immediate laboratory assessment.

Blood tests for easy bruising

Fundal bleeding ... physical findings such as bleeding in the eyes are indicators of serious haemostatic or clotting failure.

Basically, we want to make sure that the blood cells, especially platelet counts, are in the normal range, and also whether the clotting mechanisms (dependent on platelet number and function, clotting factors and vessel wall interactions) are intact.

The screening blood tests ordered consist of full blood picture and coagulation profile. It is important that the tests are done in good time and abnormal results are acted promptly as delay in diagnosis and treatment impact adversely on the immediate outlook of the disease.

Preliminary diagnosis of acute leukaemia can be made in the blood film if there are circulating leukaemic cells €“ this is especially important in acute leukaemia to avoid onset of life threatening bleeding and associated infective complications.

More specialised tests such as bone marrow examination or detailed coagulation tests e.g. factor assay, need to be performed quickly in those with abnormal screening tests. These tests may only be available at tertiary medical centres and urgent referral needs to be organised.

In dealing with cases of suspected of leukaemia, the patients should be assessed quickly by the attending specialist within a day or two. Circulating inhibitors/antibodies, especially to factor VIII, can cause almost intractable serious haemorrhage and needs urgent specialist care.

What are the treatment options?

Treatment depends solely on the underlying cause. Some patients just need reassurance while others need immediate supportive treatment as well as definitive treatment, for instance blood component transfusions and induction chemotherapy for acute leukaemia.

The supportive care for bleeding complications has improved with the used of blood component therapy. For instance, haemophilia patients are given factor concentrates while thrombocytopenic patients are given platelet transfusion, while patients with coagulopathy or multiple factors deficiency are given fresh frozen plasma (FFP) to replace the missing/deficient component.

Component therapy is certainly more effective than traditional whole blood transfusion and carries less risk of overloading patients.

The definitive treatment depends on the diagnosis. Acute leukaemia patients would need chemotherapy, and later, in some cases, bone marrow transplant to achieve the possibility of cure.

Aplastic anaemia patients would need anti-thymocyte globulin or bone marrow transplant if they have severe disease.

Immune thrombocytopenic patients are treated with steroids, immunosuppressive drugs such as azathioprine, or splenectomy in some cases.

Patients with congenital factor deficiency such as haemophilia need life-long supportive care.

Those with disseminated intravascular coagulation (DIC) need treatment of their triggering cause quickly (for instance, severe infection, shock, hypoxia) to have any chance of survival.

n This article is contributed by The Star Health & Ageing Panel, which comprises a group of panellists who are not just opinion leaders in their respective fields of medical expertise, but have wide experience in medical health education for the public.

The members of the panel include: Datuk Prof Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Datuk Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; Prof Dr Low Wah Yun, psychologist; Datuk Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Lee Moon Keen, consultant neurologist; Dr Ting Hoon Chin, consultant dermatologist; Prof Khoo Ee Ming, primary care physician; Dr Ng Soo Chin, consultant haematologist. For more information, e-mail starhealth@thestar.com.my.

The Star Health & Ageing Advisory Panel provides this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care.

The Star Health & Ageing Advisory Panel disclaims any and all liability for injury or other damages that could result from use of the information obtained from this article.

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