Prolonged bleeding (Bleeding disorders)

Prolonged bleeding can be from a few factors including:

• Defective vessel walls disorders
• Platelet disorders
• von Willebrand disease
• Haemophilia I will explain these in the following.

Defective vessel wall disorders

This is fragile skin in elderly. vasculitis, scurvy, etc

Platelet disorders

Thrombocytopenia

This is when you have low platelets in the blood. The reference interval: 150-400x10^9/L.

Bleeding bruising progressively as platelet count falls below 100x10^9/L

Defective platelet disorders

This can be due to drugs and some food that affect platelet function (aspirin etc), and some inherited conditions

Von Willebrand disease

This is defined as low levels of the vWF or an abnormal vWF molecule. Its effects are reduced platelet adhesion and prolonged bleeding.

Coagulation disorders (Haemophilias)

There are a large number of conditions which can be acquires or inherited.

Vitamin K disorders

Vitamin K is needed to produce factors 10, 9, 7, 2

Your gut microbiome usually produced vitamin K

If you are deficient in this you will not have enough clotting factors for proper clotting. This can occur in low intake of vitamin K, antibiotics, and small bowel malabsorption disorders. It can additionally be caused with neonates and premature infants

Haemophilias

This refers to 2 types of X-linked disorders

Haemophilia type A

This is a deficiency in factor 8

Haemophilia Type B

This is a deficiency in factor 9

Severity

The severity of each type is related to how much factor exists in the blood

• 1%: Is severe so bleeding is spontaneous and after minor trauma

• 2-5%: Is moderate so bleeding after minor or moderate trauma
• 5-50%: Is mild so bleeding after moderate or major trauma.

Joint bleeding

In those with haemophilia repeat joint bleeds occur eroding cartilage via recurrent inflammation.

Clinical relevance

Sufferers can exhibit

• Haemoarthrosis: bleeding into joint capsule. Crippling arthritis unless F8 levels are maintained at adequate levels.
• Muscle bleeding: muscle fibrosis and calcifaction will occur if not adequately treated
• and bleeding in other sites: can be kidney, brain uncommon, but severe.
• The skin will have large bruised after trauma.

Treatment

Lots of treatments.

Recombinant Factor 8 or Factor 9

This is effective for haemophiliacs with an inability to make the missing factors. But it doesnt work if there is immune destruction

Emicizumab

Emicizumab is an antibody which bridges factor 9a and factor 10 like how factor 8a does it. This is a subcutaneous injection performed every 1-4 wks and is availible for severe haemophilia A sufferers

Assessing bleeding disorders

History

Often you can discern a great deal of information from history (no shit)

Platelet related bleeds often are mucosal (nose, heavy periods, gut) where as joint (capsule) and muscle bleeds are more often haemophilia (as they have less TF expressed so rely on intrinsic pathway). Skin can be either or both.

Also ask about patterns of bleeding, Drug history, and Family history

Tests

The tests you do for haemophilia are

1. Blood screen to assess platelet count and morphology
2. Coagulation screen (APTT, PT, fibrinogen)
3. If these dont work test for platelet function
4. and if appropriate shoot for second stages tests
   1. von Willebrand factor assats
   2. Platelet function studies
   3. Coagulation factor assays