Bleeding disorders and risk

Incomplete information; this section will be expanded, clarified, and with references added in the future.

Guidelines

"How I treat"

• 2020: Biguzzi et al. How I treat gastrointestinal bleeding in congenital and acquired von Willebrand disease

Initial evaluation

• Bleeding history (acquired or inherited disorder?)
  • Spontaneous or provoked by surgery, tooth extraction, etc.
  • Tolerance of prior surgery
  • Menses
  • Mucocutaneous bleeding, petechiae, oozing at line sites
  • Bruising, hemarthrosis
  • Family history--known hemophilia A, hemophilia B, von Willebrand disease (VWD), platelet function disorder
  • Need for transfusion or product
• History of trauma, surgery
• PT/INR
• PTT
• Platelet count
• +/- fibrinogen (DIC), D-dimer, fibrin/fibrinogen degradation products (FDP)
• Kidney disease (uremia)
• Medications: anticoagulants, antiplatelet medications such as aspirin and Clopidogrel (Plavix), NSAIDS, antidepressants which cause decrease in platelet function
• Vitamin C (scurvy). No fruits or vegetables in diet?

Bleeding Score

This is a quantitative assessment of bleeding risk based on history, and can predict the likelihood of VWD Type I.

• ASH Pocket Guides App contains several calculators including the bleeding score calculator

1. Tosetto A, Rodeghiero F, Castaman G, Goodeve A, Federici AB, Batlle J, Meyer D, Fressinaud E, Mazurier C, Goudemand J, Eikenboom J, Schneppenheim R, Budde U, Ingerslev J, Vorlova Z, Habart D, Holmberg L, Lethagen S, Pasi J, Hill F, Peake I. A quantitative analysis of bleeding symptoms in type 1 von Willebrand disease: results from a multicenter European study (MCMDM-1 VWD). J Thromb Haemost. 2006 Apr;4(4):766-73. link to original article PubMed

Abnormal PT/INR or PTT

• 1:1 mixing study (50/50 mixing study, circulating anticoagulant)
• Liver disease
• Elevated PT only
  • Vitamin K deficiency
    • Warfarin
    • Dietary habits
    • Antibiotic use
    • Malnutrition
    • Increased gut motility
  • Deficiency or inhibitor of factor VII
  • Lupus anticoagulant (rarely)
• Elevated PTT only
  • Heparin
  • Deficiencies of factor VIII, factor IX, factor XI, factor XII, or inhibitors.
  • Not associated with increased bleeding risk: Prekallikrein deficiency, high molecular weight kininogen deficiency, factor XII deficiency
  • von Willebrand disease
  • Lupus anticoagulant
• Elevated PT & PTT
  • Deficiences of prothrombin (factor II), factor V, factor X, fibrinogen
  • DIC