Bleeding Disorders

Question 1

Causes of excess bleeding (not surgical or from diseases after atherosclerosis)

Answer 1

Over-anticoagulation
Disseminated intravascular coagulation
Platelet disorders

Question 2

Pathophysiology of over-anticoagulation

Answer 2

Anticoagulation causes the blood to inappropriately avoid clotting -> Bleeding

Question 3

What factors are blocked by Warfain?

Answer 3

2, 7, 9, 10

Question 4

Aetiology of over-anticoagulation

Answer 4

Iatrogenic

inappropriate prescription of warfarin or heparin

Question 5

Treatment of patients with excess bleeding as a result of warfarin overdose

Answer 5

Phytomenadione

Question 6

Treatment of patients with excess bleeding as a result of heparin overdose

Answer 6

protamine sulfate

Question 7

What is meant by disseminated intravascular coagulation

Answer 7

Coagulation systems (thrombin) activated inappropriately

Question 8

Clinical presentation of disseminated intravascular coagulation

Answer 8

Underlying condition treat
Bleeding from unrelated sites (ENT, GI, response, site of venipuncture)
Confusion, fever
Skin: Purpura, petechiae, localised infarction

Question 9

Pathophysiology of Disseminated Intravascular Coagulation

Answer 9

Clotting occurs inappropriately and diffusely, until clotting factors are exhausted.
At this point uncontrolled bleeding occurs

Question 10

Aetiology of Disseminated Intravascular Coagulation

Answer 10

Secondary to infection, malignancy, major trauma

Question 11

Diagnostic tests of Disseminated Intravascular Coagulation

Answer 11

Prothrombin time elevated
Activated partial thromboplastin time elevated
Platelets low
Fibrinogen low

Question 12

Treatment of Disseminated Intravascular Coagulation

Answer 12

Consider transfusion of platelets

Question 13

Complications of Disseminated Intravascular Coagulation

Answer 13

Organ failure by infarction, death

Question 14

Examples of platelet disorders

Answer 14

Immune thrombocytopenic purpura

Thrombotic thrombocytopenic purpura

Question 15

Clinical presentation of Immune thrombocytopenic purpura

Answer 15

Rapid onset of purpura (usually self limiting in children).
Easy bruising, epistaxis and menorrhage.
Major haemorrhage is rare.

Question 16

What is Immune thrombocytopenic purpura

Answer 16

Immune destruction of platelet cells

Question 17

Pathophysiology of Immune thrombocytopenic purpura

Answer 17

Formation of antibodies against platelets -> Autoimmune Platelet destruction -> thrombocytopenia. The spleen is the site of autoantibody

Question 18

What are purpura

Answer 18

A rash of purple spots on the skin caused by internal bleeding from small blood vessels

Question 19

Children Aetiology of Immune thrombocytopenic purpura

Answer 19

a result of viral infection

Question 20

Adult aetiology of Immune thrombocytopenic purpura

Answer 20

occurs in combination with another autoimmune condition (SLE etc)

Question 21

Epidemiology of Immune thrombocytopenic purpura

Answer 21

5/100,000 in children

2/100,000 in adults

Question 22

Diagnostic test of Immune thrombocytopenic purpura

Answer 22

FBC - isolated thrombocytopenia

Question 23

Treatment of Immune thrombocytopenic purpura

Answer 23

Oral corticosteroids (prednisolone)
Second line: splenectomy

Question 24

Clinical presentation of Thrombotic thrombocytopenic purpura

Answer 24

Florid purpura
Fever
Fluctuating cerebral dysfunction 
Haemolytic anaemia
Often renal failure

Question 25

Pathophysiology of Thrombotic thrombocytopenic purpura

Answer 25

Deficiency of ADAMTS 13 (protease which degrades vWF) -> Widespread adhesion and aggregation of platelets -> microvascular thrombosis -> profound thrombocytopenia

Question 26

Aetiology of Thrombotic thrombocytopenic purpura

Answer 26

Congenital (genetic absence of ADAMTS 13) or autoantibody mediated (autoantibody against ADAMTS 13)

Question 27

Diagnosis of Thrombotic thrombocytopenic purpura

Answer 27

Raised lactate dehydrogenase levels (from ischaemic or necrotic cells)

Question 28

Treatment of Thrombotic thrombocytopenic purpura

Answer 28

Plasma exchange to remove autoantibodies to ADAMTS 13

Splenectomy as a last resort