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Bruising and Bleeding

By

Michael B. Streiff

, MD, Johns Hopkins University School of Medicine

Reviewed/Revised Oct 2023 | Modified Nov 2023
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Bruising or bleeding after an injury is normal (see also How Blood Clots How Blood Clots Hemostasis is the body's way of stopping injured blood vessels from bleeding. Hemostasis includes clotting of the blood. Too little clotting can cause excessive bleeding from minor injury Too... read more ). However, some people have disorders that cause them to bruise or bleed too easily. Sometimes people bleed without any obvious triggering event or injury. Spontaneous bleeding may occur in almost any part of the body, but it is most common in the nose and mouth and the digestive tract.

People with hemophilia Hemophilia Hemophilia is a hereditary bleeding disorder caused by a deficiency in one of two blood clotting factors: factor VIII or factor IX. Several different gene abnormalities can cause the disorder... read more often bleed into their joints or muscles. Most often, bleeding is minor, but it can be severe enough to be life-threatening. However, even minor bleeding is dangerous if it occurs in the brain.

Several symptoms may suggest that a person has a bleeding disorder:

  • Unexplained nosebleeds (epistaxis)

  • Excessive or prolonged menstrual blood flow (menorrhagia)

  • Prolonged bleeding after minor cuts, blood drawing, minor surgical or dental procedures, or tooth brushing or flossing

  • Unexplained skin marks, including tiny dots that may appear red or purple on light skin and brown on dark skin (petechiae), patches that appear red or purple on light skin and brown on dark skin (purpura), bruises (ecchymoses), or small blood vessels that are widened and therefore visible in the skin or mucous membranes (telangiectasias)

Skin Symptoms That Suggest a Bleeding Disorder

Sometimes a laboratory test done for some other reason shows the person has a susceptibility to bleeding.

Causes of Bruising and Bleeding

Three things are needed to help injured blood vessels stop bleeding: platelets Platelets The main components of blood include Plasma Red blood cells White blood cells Platelets read more Platelets (blood cells that help in blood clotting How Blood Clots Hemostasis is the body's way of stopping injured blood vessels from bleeding. Hemostasis includes clotting of the blood. Too little clotting can cause excessive bleeding from minor injury Too... read more ), blood clotting factors (proteins largely produced by the liver and by certain cells that line blood vessels), and blood vessel narrowing (constriction). An abnormality in any of these factors can lead to excessive bleeding or bruising:

Platelet disorders first cause small dots that appear red or purple on light skin and brown on dark skin (called petechiae). Later, if the disorder becomes severe, bleeding may occur. A decrease in blood clotting factors usually causes bleeding and bruising. Defects in blood vessels usually cause red or purple spots and patches on light skin and brown or dark patches on dark skin, rather than bleeding.

Senile purpura and purpura simplex

Most commonly, easy or excessive bruising occurs because the skin and blood vessels are fragile. Women are commonly affected with purpura simplex Purpura Simplex Purpura simplex is increased bruising that is due to fragile blood vessels. Purpura simplex is extremely common. The cause is not known. Some doctors think it may be a feature of many disorders... read more Purpura Simplex . Older adults are commonly affected with senile purpura. Bruises tend to develop on the thighs, buttocks, and upper arms. However, people have no other symptoms of excessive bleeding, and blood test results are normal. These conditions are not serious, and no treatment is needed.

Common causes

Overall, the most common causes of easy bleeding include

Platelet deficiency can be due to inadequate production of platelets by the bone marrow or excessive destruction of platelets (for example, by an enlarged spleen Enlarged Spleen An enlarged spleen is not a disease in itself but the result of an underlying disorder. Many disorders can make the spleen enlarge. Many disorders, including infections, anemias, and cancers... read more or certain medications or infections).

People who have a tendency to form blood clots may take heparin, warfarin, or direct oral anticoagulants (including dabigatran, apixaban, edoxaban, and rivaroxaban) to decrease that tendency (see Medications and blood clots Medications and blood clots Hemostasis is the body's way of stopping injured blood vessels from bleeding. Hemostasis includes clotting of the blood. Too little clotting can cause excessive bleeding from minor injury Too... read more ). However, sometimes these medications decrease the body's clotting ability too much, and people have bleeding and/or bruising.

Less common causes

Hemophilia Hemophilia Hemophilia is a hereditary bleeding disorder caused by a deficiency in one of two blood clotting factors: factor VIII or factor IX. Several different gene abnormalities can cause the disorder... read more is a hereditary disorder in which the body does not make enough of one of the clotting factors. People have excessive bleeding into deep tissues such as muscles, joints, and the back of the abdominal cavity, usually following minor trauma. Bleeding may occur in the brain, which can be fatal.

Certain disorders trigger the clotting system throughout the body. Instead of causing blood clots everywhere, platelets and clotting factors are quickly used up and bleeding occurs. This process, called disseminated intravascular coagulation Disseminated Intravascular Coagulation (DIC) Disseminated intravascular coagulation is a condition in which small blood clots develop throughout the bloodstream, blocking small blood vessels. The increased clotting depletes the platelets... read more (DIC), can be triggered by many conditions, including severe infections, severe injury, labor and delivery, and certain cancers. People with DIC are often already in a hospital. They bleed excessively from needle punctures and often have significant digestive tract bleeding.

Table

Evaluation of Bruising and Bleeding

Doctors first try to establish whether the person's symptoms actually represent easy or excessive bleeding. If so, they look for possible causes. The following information can help people know when to see a doctor and help them know what to expect during the evaluation.

Warning signs

In people with easy bruising or bleeding, certain symptoms and characteristics are cause for concern. They include

  • Symptoms of serious blood loss, such as sweating, weakness, faintness or dizziness, nausea, or extreme thirst

  • Pregnancy or recent delivery

  • Signs of infection, such as fever, chills, diarrhea, or feeling ill all over

  • Headache, confusion, or other sudden symptoms related to the brain or nervous system

When to see a doctor

People with warning signs should see a doctor right away, as should those who are still bleeding and those who have lost more than a small amount of blood. People without warning signs who notice that they bleed or bruise easily should call their doctor. The doctor determines how quickly to evaluate people based on their symptoms and other factors. Typically, people who do not feel well or have risk factors for bleeding, such as liver disease or use of certain medications, or who have a family history of a bleeding disorder should be seen within a day or two. People who feel well but had a few nosebleeds that stopped on their own or who have bruises or spots on their skin can be seen when practical. A delay of a week or so is unlikely to be harmful.

What the doctor does

Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination sometimes suggests a cause of the bleeding or bruising, but typically tests need to be done.

Doctors ask about types of bleeding, including frequent nosebleeds, gum bleeding while tooth brushing, coughing up blood (hemoptysis), blood in stool or urine, or dark tarry stool (melena). They also ask about other symptoms, including abdominal pain and diarrhea (suggesting a digestive disorder), joint pain (suggesting a connective tissue disorder), and lack of menstrual periods and morning sickness (suggesting pregnancy). They ask about whether the person is taking medications (such as aspirin, indomethacin, heparin, or warfarin) that are known to increase the risk of bleeding. Easy bleeding in a person taking warfarin, especially if the dose has recently increased, is likely due to the medication. Doctors also ask if the person has a condition that is likely to cause a problem with blood clotting, such as

People are asked about use of alcohol or intravenous (IV) drugs. Heavy alcohol use is a risk factor for liver disease, and IV drug use is a risk factor for HIV infection.

During the physical examination, doctors check vital signs (temperature, blood pressure, and heart rate). These signs can give an early indication of serious disorders, especially low blood volume or an infection. A high heart rate together with low blood pressure suggests low blood volume due to bleeding. Fever suggests an infection.

Doctors examine the skin and mucous membranes (nose, mouth, and vagina) looking for signs of bleeding. A digital rectal examination is done to look for bleeding from the digestive tract. Doctors also look for signs, such as tenderness during movement and local swelling, that may indicate bleeding in deeper tissues. A person with bleeding inside the head may have confusion, a stiff neck, or neurologic abnormalities (such as headache, vision problems, or weakness). The sites of bleeding may offer a clue to the cause. Bleeding from superficial sites, including skin and mucous membranes, suggests a problem with platelets or blood vessels. On the other hand, bleeding into deep tissues suggests a problem with clotting.

Additional findings may help doctors narrow the cause. Accumulation of fluid in the abdomen (ascites), an enlarged spleen (splenomegaly), and yellow color of the skin and/or eyes (jaundice) suggest bleeding caused by liver disease. A woman who is pregnant or has recently delivered or a person who is in shock Shock Shock is a life-threatening condition in which blood flow to the organs is low, decreasing delivery of oxygen and thus causing organ damage and sometimes death. Blood pressure is usually low... read more or has a fever, chills, and other signs of serious infection is at risk of disseminated intravascular coagulation Disseminated Intravascular Coagulation (DIC) Disseminated intravascular coagulation is a condition in which small blood clots develop throughout the bloodstream, blocking small blood vessels. The increased clotting depletes the platelets... read more . In children, fever and digestive upset, especially bloody diarrhea, suggest hemolytic-uremic syndrome Hemolytic-Uremic Syndrome (HUS) Hemolytic-uremic syndrome (HUS) is a serious disorder that usually occurs in children and involves the formation of small blood clots throughout the body that block the flow of blood to vital... read more . A rash on the legs, joint pain, and digestive upset suggest immunoglobulin─A associated vasculitis Immunoglobulin A–Associated Vasculitis Immunoglobulin A–associated vasculitis (formerly called Henoch-Schönlein purpura) is inflammation of mainly small blood vessels that most often occurs in children. A rash of reddish purple bumps... read more Immunoglobulin A–Associated Vasculitis .

Testing

Most people with excessive bleeding require blood tests. The initial tests are

These tests are considered screening tests. They are done to determine whether the clotting system is normal. If one of these tests reveals an abnormality, additional tests are usually needed to identify the cause.

Imaging tests are often done to detect internal bleeding in people with bleeding disorders. For example, computed tomography Computed Tomography (CT) Computed tomography (CT) is a type of medical imaging that combines a series of x-rays to create cross-sectional, detailed images of internal structures. In computed tomography (CT), which used... read more Computed Tomography (CT) (CT) of the head should be done in people with severe headaches, head injuries, or impairment of consciousness. Abdominal CT is done in people with abdominal pain.

Tests of the Blood Clotting System

Treatment of Bruising and Bleeding

The specific treatment for easy bruising and bleeding depends on the cause. For example,

  • Cancers and infections are treated

  • Medications that cause bleeding are stopped

  • Vitamins are given for vitamin deficiency

  • People with liver disease are sometimes given vitamin K or fresh frozen plasma transfusions

People with easy bruising due to skin and blood vessel fragility do not need to be treated, although doctors sometimes suggest that people avoid taking aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).

Essentials for Older Adults: Bruising and Bleeding

Older adults may be more prone to easy bruising. As people age, the skin thins and people lose some of the protective layer of fat below the skin surface. So a minor bump is more likely to cause blood vessels to break, leading to bruising. Also, the small blood vessels themselves become less elastic and more fragile, leading to easier bruising. Older adults also are more likely to take aspirin, clopidogrel, warfarin, or direct oral anticoagulants, which make bruising and bleeding more likely.

Key Points

  • Excessive bleeding may occur on its own or after minor injury.

  • Bleeding can range from minimal to massive and is very dangerous if it occurs within the brain.

  • Liver disease, low platelet count, and certain medications (especially warfarin, heparin, aspirin, and nonsteroidal anti-inflammatory drugs ) are common causes.

  • Disseminated intravascular coagulation is an uncommon but serious cause that most often develops in people who are already ill or in the hospital.

  • Easy bruising is common and is rarely a cause for concern if people feel well and have no other signs of easy bleeding.

Drugs Mentioned In This Article

Generic Name Select Brand Names
Hepflush-10 , Hep-Lock, Hep-Lock U/P, Monoject Prefill Advanced Heparin Lock Flush, SASH Normal Saline and Heparin
Coumadin, Jantoven
Pradaxa
Eliquis
Savaysa
Xarelto, Xarelto Granules, Xarelto Starter Pack
Anacin Adult Low Strength, Aspergum, Aspir-Low, Aspirtab , Aspir-Trin , Bayer Advanced Aspirin, Bayer Aspirin, Bayer Aspirin Extra Strength, Bayer Aspirin Plus, Bayer Aspirin Regimen, Bayer Children's Aspirin, Bayer Extra Strength, Bayer Extra Strength Plus, Bayer Genuine Aspirin, Bayer Low Dose Aspirin Regimen, Bayer Womens Aspirin , BeneHealth Aspirin, Bufferin, Bufferin Extra Strength, Bufferin Low Dose, DURLAZA, Easprin , Ecotrin, Ecotrin Low Strength, Genacote, Halfprin, MiniPrin, St. Joseph Adult Low Strength, St. Joseph Aspirin, VAZALORE, Zero Order Release Aspirin, ZORprin
Indocin, Indocin SR, TIVORBEX
Plavix
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