Evaluation of easy bruising

Summary

A bruise (ecchymosis) is caused by bleeding beneath the skin as a result of extravasation of blood from surrounding blood vessels. It may develop due to abnormalities in hemostasis or alteration in the structural integrity of the blood vessel wall and surrounding subcutaneous tissue.

Easy bruising implies that no significant trauma has occurred to the skin or soft tissue to cause the bruise, and the bruises are larger and/or more frequent than what would normally be seen. It is a common complaint of patients seen in a medical practice. Surveys of normal healthy individuals report the frequency of easy bruising to range from 12% to 55%.[1] [2]

Causes vary from those with no significant clinical consequence to underlying diseases that could be life-threatening such as severe bleeding disorders or bone marrow malignancies. Appropriate evaluation is crucial in reaching the correct diagnosis and treatment; therefore, a structured approach that incorporates the history, physical exam, and laboratory studies should be utilized. However, laboratory testing is costly and results can be confusing and require an experienced physician for proper interpretation.

Referral to a hematologist for further evaluation may be needed. Appropriate evaluation is especially important before invasive procedures.

Library

Large bruise on the abdomen of a patient on warfarin with acquired factor V inhibitor
Bruising affecting the thigh and pelvic area in a patient with vitamin C deficiency
Bruising in patient with vasculitis (drug-induced)
Diagnostic algorithm for the workup of easy bruising (*Test usually not ordered in the US)

Citations

Key Articles

Faughnan ME, Mager JJ, Hetts SW, et al. Second international guidelines for the diagnosis and management of hereditary hemorrhagic telangiectasia. Ann Intern Med. 2020 Dec 15;173(12):989-1001.[Abstract][Full Text]
Tiede A, Collins P, Knoebl P, et al. International recommendations on the diagnosis and treatment of acquired hemophilia A. Haematologica. 2020 Jul;105(7):1791-801.[Abstract][Full Text]
Neunert C, Terrell DR, Arnold DM, et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv. 2019 Dec 10;3(23):3829-66.[Abstract][Full Text]
Rodeghiero F, Tosetto A, Abshire T, et al. ISTH/SSC bleeding assessment tool: a standardized questionnaire and a proposal for a new bleeding score for inherited bleeding disorders. J Thromb Haemost. 2010;8:2063-2065.[Abstract][Full Text]
Platton S, Baker P, Bowyer A, et al. Guideline for laboratory diagnosis and monitoring of von Willebrand disease: a joint guideline from the United Kingdom Haemophilia Centre Doctors' Organisation and the British Society for Haematology. Br J Haematol. 2024 May;204(5):1714-31.[Full Text]

Other Online Resources

University of Oklahoma Health Sciences Center: platelets on the web - drug-induced thrombocytopenia
International Society on Thrombosis and Haemostasis: bleeding assessment tool

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