WebMD Scientific American® Medicine

Whereas many healthy people consider their bleeding and bruising excessive, patients with underlying von Willebrand disease, the most common hereditary bleeding disorder, often fail to identify their bleeding symptoms. Therefore, it is necessary to ask for specific information from patients about bleeding and bruising (Is the patient easily bruised? What is the size of the bruises? If the patient has had surgery, were blood transfusions needed?). If the patient had a wisdom tooth extracted, were return visits required for packing, suturing, or transfusion? The patient should be questioned about drug use (including intravenous drug abuse), sexual activity, anemia, transfusions, recurrent infections, connective tissue diseases, malignancies, and immunocompromised states. The type of bleeding is informative. Active bleeding can be caused by a localized anatomic lesion or an underlying bleeding diathesis. Mucosal bleeding, with recurrent epistaxis, gum bleeding, ecchymoses, and menorrhagia, is suggestive of von Willebrand disease or other platelet disorders. Deep-tissue bleeding (e.g., hemarthrosis and painful muscle hematomas) is more commonly seen in hemophilia and clotting factor deficiencies. Patients with clotting factor deficiencies may have delayed bleeding, presumably because the initial platelet thrombus provides immediate hemostasis but is not properly stabilized by the fibrin clot. Aspirin can partially impair platelet function and trigger bleeding symptoms in a patient with mild underlying von Willebrand disease. Because several hundred drug formulations contain aspirin (often with no indication of aspirin content in the product name), identification of aspirin as the cause of a hemorrhagic disorder can be difficult.