Bleeding D/O

Question 1

MCC of abnormal bleeding

Answer 1

thrombocytopenia

Question 2

Idiopathic thrombocytopenic purpura (ITP) general

Answer 2

IgG d/o; chronic peaks from 20 to 50 y/o, more CMN in women

Question 3

ITP s/sx

Answer 3

petechiae on skin/mucous membranes; rarely febrile – also present w/ epistaxis, oral bleeding, menorrhagia, USU NO SPLENOMEGALY

Question 4

MCC of ITP in hospitalized

Answer 4

heparin (HIT); other causes: sulfonamides, quinine, thiazides, cimetidine, gold
SLE and CLL can cause it too

Question 5

ITP (acute and chronic) lab findings

Answer 5

acute: platelets- 10-20k, eosinos, mild lymphocytosis
chronic: platelets- 25-75k
mild anemia

Question 6

ITP peripheral smear

Answer 6

megathrombocytes; NML coag studies

Question 7

ITP tx

Answer 7

acute: usu self-limited, some req. CS or splenectomy
chronic: RARELY self-lim, initial tx: HD prednisone, splenectomy usu definitive
life-threatening bleed: platelet transfusion!

Question 8

Thrombotic Thrombocytopenia Purpura (TTP) general

Answer 8

rare, but often fatal
mostly b/w 20-50 y/o, previously healthy people
More in women, HIV patients

Question 9

TTP precipitated by…

Answer 9

estrogen use, pregnancy, drugs (quinine and ticlopidine)

Question 10

TTP-like syndrome in kids

Answer 10

HUS (hemolytic uremia syndrome): < 10y/o usu., particularly after infxn w/ e. coli (0157:H7), shigella, salmonella
Can be seen in adults w/ estrogen use and pregnancy

Question 11

TTP s/sx

Answer 11

severe thrombocytopenia w/ purpura/petechiae, pallor, abd pain, fever, abnl neuro, renal failure
POSS pancreatitis
microangiopathic hemolytic anemia

Question 12

HUS s/sx

Answer 12

similar to TTP, but NO neuro findings

More renal problems than TTP

Question 13

DIC s/sx

Answer 13

skin and mucous membrane bleeding, shock CMN, thrombosis less CMN

Question 14

TTP and HUS lab findings

Answer 14

anemia, red cell fragments (schistocytes), NML WBC, polychromatophilia, reticulocytosis, thrombocytopenia (LESS severe in HUS)

INC LDH, indirect bili
NML coag tests

Question 15

DIC labs

Answer 15

HYPOfibrinogenemia
INC fibrin degradation products (D-DIMER IS MOST SENSITIVE)
thrombocytopenia
PROLONGED PT
microangiopathic hemolytic anemia w/ schistocytes in 25% of cases

Question 16

TTP tx

Answer 16

EMERGENT large-vol. plasmapherresis

Prednisone and ANTI-platelet agents

Question 17

HUS tx

Answer 17

conservative mgmt in kids: fluids, electrolyte balance

adults: plasmapheresis

Question 18

DIC tx

Answer 18

PROMPT and aggressive tx of underlying cause
Replace finbrinogen
(heparin is controversial)

Question 19

Platelet dysfxn general

Answer 19

more CMNly acquired than congenital
MCC: asa and NSAID
also w/ uremia, alcoholism, myeloproliferative dz, hypothermia, vitamin deficiencies

Question 20

VWD general

Answer 20

VWF: AUTOSOMAL dominant
MC congenital coagulopathy
most are mild
6 types, but type 1 is 75-80%

Question 21

VWD patho

Answer 21

DEC lvls of factor 8 Ag or ristocetin cofactor

Question 22

difference b/w hemophilia A and VWD

Answer 22

Hemo A: MORE spontaneous hemarthrosis and soft-tissue bleeds

Question 23

VWD s/sx

Answer 23

nasal, sinus, vaginal, and GI mucous membrane bleeds
WORSENED: w/ asa
BETTER w/ estrogen use, pregnancy

Question 24

VWD labs

Answer 24

PT and PTT generally NML
bleeding time usually prolonged
VWF low

Question 25

VWD tx

Answer 25

type 1: desmopressin acetate | Factor 8 preferred if factor replacement is necessary

Question 26

Hemophilia A general

Answer 26

``` factor 8 or classic hemophilia MC congenital coagulopathy after VWD most severe bleeding d/o X-linked recessive (1 in 7500 males) genetic mutation causes 1/3 of cases ```

Question 27

hemophilia A s/sx

Answer 27

hemarthoses, epistaxis, IC bleeding, hematemesis, melena, microscopic hematuria, bleeding into soft tissue and gingiva

Question 28

hemophilia A labs

Answer 28

PTT prolonged PT, bleeding time, fibrinogen level, platelets NML DEC factor 8 FEMALE CARRIERS: low/nml factor 8

Question 29

hemophilia A tx

Answer 29

infusion of heat-tx or recombinant factor 8 desmopressin can elevate factor 8 in pts w/ mild-mod dz AVOID asa, celecoxib or opioids

Question 30

Hemophilia B gen

Answer 30

factor 9 deficiency or Xmas dz | X-linked recessive (1/25000 males)

Question 31

Factor 11 deficiency

Answer 31

Ashkenazi Jews mild, AUTOSOMAL REC tx w/ FFP (fresh frozen plasma)

Question 32

Vit K dependent factor deficiencies

Answer 32

MC ACQUIRED coagulopathies

Question 33

Vit K deficiency causes

Answer 33

poor diet, liver failure, malabsorption, malnutrition, drugs (broad spectrum ABX)

Question 34

vit K s/sx

Answer 34

typical pt is post op, not eating well, on broad ABX | soft tissue bleeding

Question 35

vit k def labs

Answer 35

PT prolonged, PTT may be prolonged NML: fibrinogen, thrombin time, platelets elev liver enz vit K, factors 2, 7, 9, and 10 DEC

Question 36

vit k def tx

Answer 36

tx underlying cause PO or parenteral vit K (phytonadione) tx hemorrhage w/ FFP diet high in leafy vegetables, tx malabsorption