Bruising

💡 Key Clinical Pearl: - Platelet problems → mucosal bleeding & petechiae. - Clotting factor deficiencies → deep tissue bleeding & haemarthroses. - Vascular disorders → palpable purpura, often with systemic features.

💜 Bruising (ecchymosis, purpura) refers to discolouration of the skin or mucosa due to blood leakage from damaged vessels into tissues. It can be benign and trauma-related or a sign of a serious underlying disease such as thrombocytopenia, leukaemia, or coagulopathy. The pattern, history, and associated symptoms are key to diagnosis.

🗣️ Clinical Discussion

• 📖 History:
  • Onset and duration — sudden widespread bruising suggests an acquired disorder (DIC, drugs); long-standing history may point to inherited causes (haemophilia, von Willebrand disease).
  • Precipitating factors — trauma, medication use (anticoagulants, steroids), infections, recent viral illnesses in children (ITP trigger).
  • Associated bleeding symptoms — epistaxis, gum bleeding, menorrhagia, haemarthroses, or GI bleeding.
  • Systemic symptoms — fever, weight loss, night sweats (malignancy), fatigue (anaemia).
  • Dietary history — poor intake of vitamin C or K.
• 🩺 Examination:
  • Pattern of bruising: small petechiae = platelet problem; large ecchymoses = clotting factor problem; palpable purpura = vasculitis.
  • Distribution: lower limb bruising is common and benign; trunk/face bruising without trauma is concerning.
  • Lymphadenopathy or hepatosplenomegaly — suggestive of leukaemia or systemic disease.
  • Signs of chronic liver disease — spider naevi, jaundice, ascites.
  • Safeguarding red flag: multiple bruises at different healing stages in children.
• 🔬 Investigations:
  • Start with CBC, clotting profile, LFTs.
  • Add ESR/CRP if inflammatory disease suspected.
  • Specialised: factor assays, marrow biopsy, autoantibody panels as guided by clinical suspicion.

📊 Categories of Causes

• ⚒️ Mechanical: Trauma, injury.
• 🩸 Platelet disorders: Thrombocytopenia, ITP.
• 🧬 Clotting factor disorders: Haemophilia, DIC.
• 🫀 Systemic disease: Liver failure, leukaemia.
• 💊 Drug-induced: Anticoagulants, antiplatelets, steroids.
• 🍊 Nutritional: Vitamin C deficiency (scurvy).
• 🔥 Vascular inflammation: Vasculitis, HSP.

🔬 Investigations in Bruising

• 🧪 Blood tests: CBC (platelets, WCC, Hb), coagulation profile (PT, aPTT, INR), fibrinogen, D-dimer.
• 🧬 Biochemistry: LFTs (synthetic function), U&E (renal involvement).
• 🧪 Specialised: Factor assays (haemophilia), von Willebrand testing, vitamin C levels, ANCA if vasculitis suspected.
• 📸 Imaging: Ultrasound/CT if organ bleeding suspected; X-ray if associated with trauma.
• 🔬 Bone marrow biopsy: If leukaemia or marrow failure suspected.

🩺 Causes, Tests & Management

⚠️ Red Flags in Bruising

• Unexplained, recurrent or widespread bruising.
• Associated with fever, weight loss, lymphadenopathy.
• Bleeding gums, nosebleeds, or prolonged bleeding after minor trauma.
• Child with multiple bruises in different stages → consider safeguarding.
• Bruising with shock signs → suspect DIC or major haemorrhage.

🧑‍⚕️ Case Examples

Case 1: 👩 A 7-year-old girl presents with widespread bruising and petechiae. CBC shows platelets 12 ×10⁹/L, normal Hb and WCC. Diagnosis: Immune thrombocytopenia (ITP). ✅ Managed with corticosteroids and close monitoring.

Case 2: 👨 A 62-year-old man with a history of atrial fibrillation on warfarin presents with large spontaneous thigh bruises. INR = 6.2. ✅ Managed with IV vitamin K and temporary cessation of warfarin, with dose re-adjustment after stabilisation.