Focus on suspected hemorrhagic diathesis

Michael Iarossi, MD, Cédric Hermans, MD, PhD, FRCP (Lon, Edin) Published in the journal : September 2023 Category : Hematology/Oncology

Summary :

Clinical bleeding manifestations are commonly encountered reasons for medical consultations in both general and specialized fields. A comprehensive medical history, encompassing personal and familial contexts, plays a pivotal role in predicting a bleeding disorder. Employing a bleeding clinical score constitutes the primary approach. While routine coagulation tests are useful, they are inadequate for definitively ruling out a potential hemostatic abnormality. If a strong suspicion of hemostasis dysfunction exists, a comprehensive array of biological assessments must be requested. This evaluation should encompass primary hemostasis, coagulation factors, and fibrinolysis. This combined clinical and biological strategy is instrumental in recognizing whether a coagulation disorder is acquired or hereditary, in elucidating its underlying cause, and in gauging its severity. The commonly encountered congenital causes comprise platelet functional disorders, von Willebrand disease, hemophilia A/B, and deficiencies in coagulation factors like Factor VII and Factor XI, as well as hyperfibrinolysis. Nonetheless, a notable subset of patients is unlikely to benefit from this diagnostic approach. This prompts us to an undetermined source of the bleeding tendency, necessitating cautious attention to its potential implications. For hemostatic interventions, it is crucial to exercise vigilance. Indeed, the aim of such procedures is to attain effective management or bleeding prevention, while sidestepping unnecessary treatments with inherent risks, such as allergies, immunization, infections, and even thrombotic complications.


Hemorrhagic diathesis, Coagulation assessment, Blee-ding assessment tool, Primary hemostasis, Coagulation cascade, Fibrinolysis, Congenital and acquired disorders, Hemostatic therapy, Bleeding of unknown cause

Key messages

- Hemorrhagic symptoms are common in both general and specialized medical fields, also concerning patients receiving hospital care.

- A comprehensive evaluation of personal and family medical histories is pivotal for distinguishing between acquired and hereditary conditions, revealing insights into the etiology and severity of the condition.

- Despite its limitations, a bleeding score is essential for confirming an abnormal bleeding tendency.

- While routine tests for hemostasis (APTT, PT, Fg, and TT) offer valuable information, they only provide a confined perspective on the intricate coagulation process.

- If the medical history raises concerns and the initial tests yield normal results, a comprehensive assessment should be conducted including evaluation of primary hemostasis, coagulation factors, and fibrinolysis.

- Commonly identified etiologies include von Willebrand disease, platelet functional defect, hemophilia, factor deficiencies (Factor VII, Factor XI), and increased fibrinolysis.

- Despite a positive medical history, a subset of patients exhibits negative results upon the work-up, presenting bleeding of unknown cause (BUC).

- Prudent utilization of available hemostatic treatments is essential to ensure effective management or prevention of bleeding complications, while minimizing the exposure of patients to unnecessary treatments with potential risks like allergies, immunization-related issues, infections, and thrombotic events.