Diagnosis and Treatment of Benign Bleeding Disorders

M any common bleeding disorders will be revealed through a careful examination of patient history and a mixing study, according to Ravi Krishnadasan, MD, of the University of Arizona, Tucson, Arizona. Benign bleeding disorders are understood in the context of the two main components of hemostasis: primary and secondary hemostasis. Primary hemostasis is the formation of the platelet plug, which involves platelets, von Willebrand factor, and binding to collagen. Secondary hemostasis involves factors such as factors IX, X, XI, and XII that form the protective fibrin clot as a result of a “coagulation cascade.” Platelets are involved in both types of hemostasis. At JADPRO Live at APSHO, Dr. Krishnadasan described common bleeding disorders and offered clinical pearls on evaluation and treatment. “The first and most important step is taking a careful patient history,” he stressed. “Decipher whether the pattern of symptoms is consistent with primary or secondary hemostasis.” Clinicians should ask about previous symptoms, history of procedures and transfusions, occurrence of trauma vs. spontaneous bleeds, time and age of onset, and family history. For women, estrogen exposure and pregnancy are important factors; some bleeding disorders, such as menorrhagia, improve in the presence of high estrogen. Microhemorrhage (including mucocutaneous bleeding [gums, nose]), bruising, and petechiae, are usually related to primary hemostasis. Such patients often present after experiencing heavy bleeding after a tooth extraction, for example. On the other hand, macrohemorrhage—large bleeds into the joints and muscles or widespread bruising—is associated with secondary hemostasis. One such condition is hemophilia (factor VIII or IX deficiency).