Bleeding diathesis: Difference between revisions

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== Differential Diagnosis ==
== Differential Diagnosis ==


=== Differential diagnosis of "Bleeding disorders": ===
{| class="wikitable"
{| class="wikitable"
|+
Differential diagnosis of "Bleeding disorders":
! rowspan="2" |Category
! rowspan="2" |Category
! rowspan="2" |Sub-category
! rowspan="2" |Sub-category
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! rowspan="2" |History
! rowspan="2" |History
! colspan="5" |Clinical manifestation
! colspan="5" |Clinical manifestation
! colspan="5" |Laboratory testing<ref name="pmid2535679">{{cite journal |vauthors=Burns ER, Lawrence C |title=Bleeding time. A guide to its diagnostic and clinical utility |journal=Arch. Pathol. Lab. Med. |volume=113 |issue=11 |pages=1219–24 |date=November 1989 |pmid=2535679 |doi= |url=}}</ref>
! colspan="5" |Laboratory testing
! rowspan="2" |Comments
! rowspan="2" |Comments
|-
|-
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|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|-
|-
| colspan="2" |[[Von Willebrand disease|Von Willebrand Disease]]<span name="harr_c115s002s005p001"></span><span name="9100810"></span> <ref name="pmid3487361">{{cite journal |vauthors=Gralnick HR, Rick ME, McKeown LP, Williams SB, Parker RI, Maisonneuve P, Jenneau C, Sultan Y |title=Platelet von Willebrand factor: an important determinant of the bleeding time in type I von Willebrand's disease |journal=Blood |volume=68 |issue=1 |pages=58–61 |date=July 1986 |pmid=3487361 |doi= |url=}}</ref><ref name="pmid3876122">{{cite journal |vauthors=Mannucci PM, Lombardi R, Bader R, Vianello L, Federici AB, Solinas S, Mazzucconi MG, Mariani G |title=Heterogeneity of type I von Willebrand disease: evidence for a subgroup with an abnormal von Willebrand factor |journal=Blood |volume=66 |issue=4 |pages=796–802 |date=October 1985 |pmid=3876122 |doi= |url=}}</ref>
| colspan="2" |[[Von Willebrand disease|Von Willebrand Disease]]<span name="harr_c115s002s005p001"></span><span name="9100810"></span>  
|
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* Easy bruising
* Easy bruising
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* [[Epistaxis]]
* [[Epistaxis]]
* Easy [[Bruise|bruising]]
* Easy [[Bruise|bruising]]
* [[Menorrhagia]]<ref name="pmid9482440">{{cite journal |vauthors=Kadir RA, Economides DL, Sabin CA, Owens D, Lee CA |title=Frequency of inherited bleeding disorders in women with menorrhagia |journal=Lancet |volume=351 |issue=9101 |pages=485–9 |date=February 1998 |pmid=9482440 |doi=10.1016/S0140-6736(97)08248-2 |url=}}</ref><ref name="pmid19236375">{{cite journal |vauthors=Kouides PA, Byams VR, Philipp CS, Stein SF, Heit JA, Lukes AS, Skerrette NI, Dowling NF, Evatt BL, Miller CH, Owens S, Kulkarni R |title=Multisite management study of menorrhagia with abnormal laboratory haemostasis: a prospective crossover study of intranasal desmopressin and oral tranexamic acid |journal=Br. J. Haematol. |volume=145 |issue=2 |pages=212–20 |date=April 2009 |pmid=19236375 |doi=10.1111/j.1365-2141.2009.07610.x |url=}}</ref>
* [[Menorrhagia]]
* [[Muscle]] bleeds
* [[Muscle]] bleeds
* [[Hemarthrosis]]
* [[Hemarthrosis]]
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* The severity of factor XIII deficiency bleeds can be different in different patients  
* The severity of factor XIII deficiency bleeds can be different in different patients  
|-
|-
| rowspan="3" |[[Hemophilia]]<ref name="pmid23818083">{{cite journal| author=Zimmerman B, Valentino LA| title=Hemophilia: in review. | journal=Pediatr Rev | year= 2013 | volume= 34 | issue= 7 | pages= 289-94; quiz 295 | pmid=23818083 | doi=10.1542/pir.34-7-289 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23818083  }}</ref><ref name="pmid12781551">{{cite journal| author=Bolton-Maggs PH, Pasi KJ| title=Haemophilias A and B. | journal=Lancet | year= 2003 | volume= 361 | issue= 9371 | pages= 1801-9 | pmid=12781551 | doi=10.1016/S0140-6736(03)13405-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12781551  }}</ref><ref name="pmid22321904">{{cite journal| author=Knoebl P, Marco P, Baudo F, Collins P, Huth-Kühne A, Nemes L et al.| title=Demographic and clinical data in acquired hemophilia A: results from the European Acquired Haemophilia Registry (EACH2). | journal=J Thromb Haemost | year= 2012 | volume= 10 | issue= 4 | pages= 622-31 | pmid=22321904 | doi=10.1111/j.1538-7836.2012.04654.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22321904  }}</ref>
| rowspan="3" |[[Hemophilia]]


| colspan="2" |Type A deficiency
| colspan="2" |Type A deficiency

Revision as of 13:02, 18 September 2018


Bleeding diathesis main page

Overview

Classification

Differential Diagnosis

Platelet disorders
Immune Thrombocytopenic Purpura
Thrombotic Thrombocytopenic Purpura
Hemolytic Uremic Syndrome
Thrombocytosis
Von Willebrand Disease
Coagulation disorders
Fibrinogen deficiency
Prothrombin deficiency
Factor V deficiency
Factor VII deficiency
Factor VIII deficiency
Factor IX deficiency
Factor X deficiency
Factor XI deficiency
Factor XII deficiency
High-molecular-weight kininogen deficiency
Prekallikrein deficiency
Factor XIII deficiency
Hemophilia
Rare diseases
Disseminated Intravascular Coagulation
Vitamin K Deficiency

Different types of Von-Willebrand diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Mehrian Jafarizade, M.D [2], Nazia Fuad M.D.

Overview

Bleeding diathesis is unusual susceptibility to bleed due to hypo-coagulopathies. These diseases can occur due to a disorder of homeostasis, localized process (tissue injury), or medications. Bleeding diathesis can be resulted from vessel wall injury, platelet disorders, and coagulation factor disorders. Clinical manifestation of bleeding disorders can have a wide range of symptoms from asymptomatic to symptomatic massive and life threatening bleeding. Platelet disorders mostly have skin manifestations such as petechiae, and ecchymoses. In order to find the cause of hypo-coagulopathy; there are established laboratory tests, such as peripheral blood smear, platelet count and platelet function analysis, coagulation factor deficiencies and inhibitors, fibrinolysis tests (eg. D-dimer level), bleeding time, prothrombin time, activated partial thromboplastin time, thrombin time and reptilase time.

Homostasis

Hemostasis is the process of blood clot formation at the site of bleeding. This process has 4 main phases as below:

Platelet plug formation

At the site of vascular injury platelets are activated and bound to the collagen with the surface collagen-specific glycoprotein Ia/IIa receptor. This bindings are provided by the linking of large multimeric circulating protein von Willebrand factor (vWF). Ultimately, the platelets makes a platelet clot to initially stop the bleeding.

Coagulation cascade

Antithrombotic control

Fibrinolysis

For more information click here, and here.

Classification

Disorders of hemostasis can be classified into two main categories: platelet disorders, and disorders of coagulation. Each category can be further classified as bellow:

Platelet disorders:

  1. Thrombocytopenia: platelet count less than 150,000 per mm3
  2. Thromobcytosis: platelet countcmore than 450,000 per mm3
  3. Qualitative Disorders of Platelet function such as Von Willebrand Disease, inherited or acquired functional disorders.

Coagulation disorders

  1. Vessel wall disorders: Endothelial cells are lining entire vessel walls all over the body. Endothelium is an active layer responsible for inflammatory responses, angiogenesis and blood cell interactions. Endothelial cells have a very important role in hemostasis and they are regulating blood fluidity by the balance of antithrombotic/prothrombotic and vasodilatory/vasoconstrictor effects.
  2. Coagulation factor disorders:
  3. Disseminated Intravascular Coagulation
  4. Vitamin K Deficiency
  5. Coagulation Disorders Associated with Liver Failure
  6. Acquired Inhibitors of Coagulation Factors

Differential Diagnosis

Differential diagnosis of "Bleeding disorders":

Category Sub-category Diseases History Clinical manifestation Laboratory testing Comments
Petechiae Ecchymoses Menorrhagia Hematoma Hemarthrosis Platelet count Bleeding time (BT) Prothrombin time (PT) Activated partial thromboplastin time (aPTT) Thrombin time (TT)
Platelet disorders Thrombocytopenia Infection-Induced thrombocytopenia
  • History of prior infection
+ + + + + N N N -
Medications-Induced thrombocytopenia + + + + + N N N Most important par of treatment is discontinuing of the medication.
Heparin-Induced thrombocytopenia + + + + + N N For more information click here: Heparin-induced thrombocytopenia.
Immune Thrombocytopenic Purpura (ITP) + + + + + N N N -
Inherited Thrombocytopenia
  • Family history
+ + + + + N N N -
Thrombotic Thrombocytopenic Purpura (TTP) History of: + + + + + N N N -
Hemolytic Uremic Syndrome History of:
  • Infections
+ + + + + N N N -
Thromobcytosis +/- +/- Ν/↑ ɴ ɴ N -
Qualitative Disorders of Platelet Function Inherited Disorders of Platelet Function Glanzmann’s thrombasthenia
  • Positive family history
+ + + - Rare N/↓ ɴ ɴ N
  • AR inheritance
  • Absence of the platelet Gp IIb/IIIa receptor/
  • Diminished for GP 2B-3A on flow cytometry
Bernard-Soulier syndrome
  • Positive family history
+ + + - - N/↓ N N N
  • AR inheritance
  • Absence of the platelet Gp Ib-IX-V receptor
  • On PBS: giant platelets
  • Ristocetin - no aggregation
Platelet storage pool disorder (SPD):
  • Positive family history
  • Hairy-cell leukemia
  • Cardiovascular bypass
+ + + - - N/↓ N N N
  • AD inheritance
  • Abnormalities of platelet granule formation
Acquired Disorders of Platelet Function + + + +/- +/- N/↓ N N N -
Von Willebrand Disease + + + +/- +/- Ν N See the table below for the details about types.
Vessel wall disorders Metabolic and Inflammatory Disorders
  • History of the underlying disease.
+ + +/- - - N ↑/N N N N -
Inherited Disorders of the Vessel Wall
  • Positive family history
+ + +/- - - N ↑/N N N N -
Coagulation factor disorders Fibrinogen deficiency Different types of the fibrinogen disorders: _ + + +/- + N
  • Impaired fibrin cross linking or clot dissolution.
  • The severity of bleeding in patients with fibrinogen disorders can be mild or severe, with higher bleeding risk in those with afibrinogenemia or lower levels of functional fibrinogen. The age of onset is also variable, with earlier onset in those with more severe deficiency.
Prothrombin deficiency + + + + + N N -
Factor V deficiency _ + + + + N N The severity of bleeding is only partly related to the degree of factor V deficiency. Some patients with undetectable plasma levels of factor V experience only relatively mild bleeding.
Factor VII deficiency + + + N N N Thrombosis occurs in inherited factor VII deficiency most cases are associated with the administration of factor VII replacement therapy
Factor X deficiency
  • Prolonged bleeding following circumcision
+ + + + + N N N -
Factor XII deficiency
  • Majority,asymptomatic
  • Recurrent miscarriages
  • Painful leg ulcers
_ _ _ _ _ N N N N
High molecular weight kininogen (HMWK) deficiency
  • Possibility of positive family history of bleeding
_ _ _ _ _ N N N N
Prekallikrein deficiency
  • Possibility of positive family history of bleeding
_ _ _ _ _ N N N N
Factor XIII deficiency Types:
  • Sub unit A mutation disease (more common)
  • Sub unit B mutation disease
  • Possibility of positive family history of bleeding
-/+ -/+ -/+ -/+ -/+ N N/ N/↑ N N
  • Impaired fibrin cross linking or clot dissolution
  • The severity of factor XIII deficiency bleeds can be different in different patients
Hemophilia Type A deficiency _ _ + + + N N N N -
Type B deficiency _ _ + + + N N N N -
Type C deficiency
  • Family history
  • Bleeding after surgery or injury
_ _ + Rare Rare N N N N -
Rare diseases Disseminated Intravascular Coagulation + + _ + + N -
Vitamin K Deficiency + + + + + N Normal or mildly prolonged N -
Different types of Von-Willebrand diseases can be differentiated from each other based on the following table:
Type of VWD Type of factor deficiency Prevalence Inheritance pattern Clinical manifestations VWF activity RIPA Factor VIII
Type 1 Quantitative/ partial 60-70% AD
  • Bleeding severity mild to severe
Type 2 2A Qualitative 10% AD/AR
  • Moderate to severe bleeding
N or ↓
2B Qualitative 5% AD N or↓
2M Qualitative <1% AD/AR
  • Moderate to severe bleeding
N or ↓
2N Qualitative <1% AR
  • Clinically similar to hemophilia A with joint, soft tissue, urinary bleeding
N N
Type 3 Complete deficiency 1-2% AR Absent

Low, 1-10%

For more information on Von Willebrand disease click here