Bleeding Disorders: Causes, Symptoms, and Treatments

Bleeding Disorders: Causes, Symptoms, and Treatments

A bleeding disorder is an abnormality in the blood clotting process, leading to unusual bleeding or abnormal blood clot formation. Bleeding disorders can be congenital or acquired, affecting one or more factors involved in the coagulation process.

# 1. Bleeding Disorders Due to Weak Vessels

Causes:

• Weak blood vessels, prone to rupture: common in the elderly, those deficient in vitamin C, PP, or those with chronic conditions such as diabetes, hypertension, etc.

• Allergic capillary inflammation (Scholein – Henoch): subcutaneous hemorrhage often in the form of dots, uniform and symmetrical, most common in the lower extremities.

Symptoms:

• Subcutaneous or mucosal bleeding.

Tests:

• Prolonged bleeding time.

• Positive tourniquet test.

# 2. Bleeding Disorders Due to Thrombocytopenia

Causes:

• Bone marrow origin: Bone marrow failure, malignant blood diseases, metastatic cancer, bone marrow disorders…

• Causes due to platelet destruction or consumption in the periphery: Due to medications, viral infections, immune thrombocytopenia, lupus erythematosus…

Symptoms:

• Polymorphic subcutaneous hemorrhage.

• Mucosal bleeding.

• Possible organ bleeding.

Tests:

• Decreased platelet count: Prolonged bleeding time, clot retraction is absent or incomplete.

• Decreased platelet quality: Prolonged bleeding time, clot retraction is absent or incomplete, decreased platelet aggregation.

# 3. Bleeding Disorders Due to Coagulation Factor Deficiency

a. Congenital Intrinsic Coagulation Factor Disorders:

• Prolonged clotting time, Howell time, APTT.

• Quantification shows decreased coagulation factors, most common is factor VIII and IX deficiency.

b. Congenital Extrinsic Coagulation Factor Disorders:

• PT prolonged (prothrombin ratio decreased).

• Quantification of coagulation factors decreased (note congenital factor VII deficiency).

c. Congenital Fibrinogen Deficiency:

• Coagulation tests in both pathways are prolonged.

d. Congenital Deficiency of Factors Belonging to the Anticoagulation System:

• Protein C, protein S, antithrombin III with clinical manifestations mainly of thrombosis and infarcts.

• Quantification of these factors is decreased.

# 4. Acquired Bleeding Disorders

a. Presence of Circulating Coagulation Inhibitors:

• Common in Lupus, can be intrinsic or extrinsic coagulation inhibitors.

b. DIC (Disseminated Intravascular Coagulation):

• Causes: Snake venom, malignant diseases, extensive tissue injury, infection, blood transfusion errors…

• Symptoms: Severe bleeding, multiple sites.

• Tests: Decreased coagulation factors due to consumption, decreased platelets, decreased prothrombin ratio, decreased fibrinogen; APTT prolonged; Positive alcohol test, positive Von-Kaulla test if in fibrinolysis stage; PDF, D-dimer increased.

c. Due to Anticoagulant Medications:

• Heparin: APTT prolonged.

• Vitamin K antagonists: PT prolonged.

# 5. Immune Thrombocytopenic Purpura (ITP)

Nature:

• Disease caused by decreased peripheral platelets, manifested as bleeding, most commonly subcutaneous bleeding in the form of dots, spots (petechiae), mucosal bleeding.

Mechanism:

• Most common is immune thrombocytopenia. The body produces antibodies against antigens on platelet membranes, and these platelets are trapped in the spleen and destroyed by macrophages.

Symptoms:

• Subcutaneous hemorrhage in the form of dots, spots (petechiae), and bruises.

• Mucosal bleeding, causing gum bleeding, nosebleeds, and possible organ bleeding such as hematuria or gastrointestinal bleeding.

• In women, often there is menorrhagia or heavier than normal menstruation.

• Brain and meningeal hemorrhage.

Tests:

• Platelet count decreased.

• Hemoglobin and red blood cells decreased or normal depending on the degree of blood loss.

• White blood cell count normal or increased, and often increased neutrophil percentage.

Treatment:

• Combination of specific and symptomatic treatment to control bleeding.

• Principle of specific treatment: use immunosuppressants with corticosteroids or other immunomodulatory drugs.

• Supportive treatment with local hemostasis, intravenous hemostatic drugs, and platelet transfusions.

# 6. Hemophilia

Nature:

• Bleeding disorder caused by transmission due to reduced or abnormal factors forming intrinsic thromboplastin (factors VIII, IX, XI).

Inheritance:

• Recessive inheritance on the X chromosome.

Symptoms:

• Difficult-to-stop bleeding in many parts of the body.

• Circumstances of occurrence: often appears after surgery, trauma, with forms: difficult-to-stop bleeding at wounds: cut fingers, tooth extraction, bruising when falling, hematoma in joints, muscles.

Tests:

• Bleeding time, platelet count, clot retraction normal.

• TT, PT normal.

• APTT, Howell, clotting time prolonged.

• Quantification of factor VIII and IX reduced depending on the severity of the disease.

Treatment:

• Replacement therapy (supplementation) of deficient factors by transfusion of blood products or recombinant factors VIII, IX.

Care:

• Care and counseling to ensure timely hospitalization, maintenance, and exercise are crucial.

# Laboratory Tests for Evaluation of Bleeding Disorders

• Bleeding time: Evaluates platelet function.

• Clot retraction: Evaluates platelet function.

• APTT (Activated Partial Thromboplastin Time): Evaluates the intrinsic pathway of coagulation.

• PT (Prothrombin Time): Evaluates the extrinsic pathway of coagulation.

• TT (Thrombin Time): Evaluates the conversion of fibrinogen to fibrin.

• Coagulation factor quantification: Evaluates the concentration of coagulation factors in the blood.

• Platelet aggregation: Evaluates the ability of platelets to aggregate.

• Alcohol test, Von-Kaulla test: Evaluates the fibrinolysis stage.

• PDF (Fibrin Degradation Products), D-dimer: Evaluates fibrin degradation.

# Note:

• This article provides general information about bleeding disorders.

• To accurately diagnose bleeding disorders, a full medical evaluation and testing by a specialist is necessary.