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MindMap Gallery Clinical diagnostic procedures and selected tests for bleeding

Clinical diagnostic procedures and selected tests for bleeding

Clinical Medicine Undergraduate Internal Medicine Hematology, understand the patient’s family medical history, drug history, surgical history, past medical history, etc.

Edited at 2024-03-08 10:23:34

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Clinical diagnostic procedures and selected tests for bleeding

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Outline

Clinical diagnostic procedures and selected tests for bleeding

Diagnosis idea 1

Determine whether it is a bleeding disorder

Detailed medical history

Understand the patient's family medical history, drug history, surgical history, past medical history, etc. Understand whether the patient has had similar symptoms before, how they manifested, and whether they have significantly worsened or decreased.

Physical examination

Including examination of skin, mucous membranes, lymph nodes, liver, spleen and other parts. Pay attention to observe whether there are ecchymosis, bleeding spots, jaundice and other symptoms on the skin, and whether the liver and spleen are enlarged, etc.

It can be roughly differentiated into abnormalities in blood vessels and platelets, coagulation disorders or other diseases; It is judged to be a quantitative abnormality or a quality defect.

screening test

1. Initial hemostasis screening test

Platelet CountPLT

PLT<100×10⁹/L, that is, thrombocytopenia

Note: At least 2 counts are required for diagnosis, and blood smear is required to observe whether the number and shape of platelets are consistent with the PLT results.

Bleeding time BT

clinical significance

Prolonged BT indicates a defect in initial hemostasis completed by blood vessels and platelets.

reason

1||| Decreased platelet count: the most common cause of prolonged BT, ITP

2||| Platelet dysfunction: Thrombthethenia, giant platelet syndrome

3||| Von Willebrand disease (vWD), prolonged BT

4||| Perivascular connective tissue disease, Down syndrome, prolonged BT

5||| Antiplatelet drugs: aspirin, dipyridamole, clopidogrel, etc. should be stopped 7 days before BT measurement

Hereditary telangiectasia, Henoch-Schönlein purpura, and Vc deficiency may cause bleeding symptoms but generally do not cause BT prolongation.

2. coagulation screening test

Plasma prothrombin time PT

Reference interval: 11~14s, it is meaningful to extend/shorten PT in control plasma by 3s

clinical significance

Prolonged PT is seen in bleeding disorders caused by reduction of exogenous coagulation factors (Ⅰ, Ⅱ, Ⅴ, Ⅶ, Ⅹ)

Congenital reduction: rare

Reduced acquisition

Liver disease, Vk deficiency (biliary tract disease, chronic enteritis), DIC

Mid to late stage of DIC (hyperfibrinolytic stage)

Clotting factors are consumed and reduced

Hyperfibrinolysis, increased fibrin degradation products, interference with fibrin production/

Therefore, PT is clinically used as a screening test before surgery or for suspected bleeding disorders and as one of the diagnostic tests for DIC.

Activated partial thromboplastin timeAPTT

Reference interval: 26~36s, which is more meaningful than extending/shortening plasma APTT by 10s

clinical significance

Prolongation is mainly seen in

Bleeding disorders caused by decreased endogenous coagulation factors (1, 2, 5, 8, 9, 10, 11, 12)

congenital reduction

Hemophilia: Deficiency of factors 8 and 9

Von Willebrand's disease: vWF deficiency leads to reduced activity of factor 8

Therefore, APTT is an important screening test for von Willebrand disease

Reduced acquisition

liver disease

Vk deficiency: biliary tract disease, chronic enteritis, extensive long-term antibiotic use

Mid to late stage of DIC (hyperfibrinolytic stage)

Bleeding disorders due to increased heparin-like anticoagulants and lupus anticoagulants

Hyperfibrinolysis: primary and secondary hyperfibrinolysis

Therefore, APTT is clinically used as a screening test before surgery or for suspected bleeding disorders, especially hemophilia and abnormal anticoagulants, and as one of the diagnostic tests for DIC.

thrombin time TT

Reference interval: 16~18s, TT is meaningfully longer than control plasma TT by more than 3s

clinical significance

TT prolongation is seen in

Hyperfibrinolysis

Seen in primary or secondary hyperfibrinolysis (DIC)

Decreased fibrinogen

Fibrin degradation products (FDP) increase, inhibit thrombin, and interfere with fibrin production.

Abnormal or hypofibrinogenemia

Too much heparin or heparin-like anticoagulant substance

Liver disease, post-radiotherapy, malignant tumors, etc., the cause of prolonged TT can be identified through the toluidine blue correction test

3. Hyperfibrinolysis screening test

Plasma fibrin(ogen) degradation products (FDP)

Reference interval: normal <5mg/L. When >10mg/L is clinically significant

clinical significance

The increase is mainly seen in

Primary hyperfibrinolysis: FDP>40mg/L or above

DIC (secondary hyperfibrinolysis): FDP>20mg/L or above, which is one of the tests for diagnosing DIC.

Plasma D-dimer (DD)

Reference interval: normal <0.5mg/L. When >0.5mg/L is clinically significant

clinical significance

Differentiate between primary and secondary hyperfibrinolysis

Primary hyperfibrinolysis: increased FDP, normal DD

Secondary hyperfibrinolysis: both FDP and DD are increased

DIC: DD>2~3mg/L

deep vein thrombosisDVT

DD<0.5mg/L, DVT can basically be eliminated

Thrombotic disease or hypercoagulable state

DD is increased and can be used as one of the screening tests.

Commonly used diagnostic tests for bleeding disorders

1. Tests related to the diagnosis of von Willebrand's disease (vWD)

Definition: vWD is a type of hereditary or acquired bleeding disorder caused by a lack of von Willebrand factor (vWF) in the plasma or abnormal molecular structure, and is inherited in an autosomal recessive manner.

vWF antigen content: vWF is mainly synthesized and secreted by vascular endothelial cells. Detection of vWF antigen content is often used as the first choice test for the diagnosis of vWD.

vWF function analysis:

Mediates the binding of platelet membrane glycoprotein Ⅰb-Ⅸ (GP Ⅰb-Ⅸ) complex to subendothelial collagen, allowing platelets to adhere to the site of vascular injury.

Binds to coagulation factor VIII and acts as a carrier to stabilize FVII

2. Tests related to diagnosis of platelet disease

Platelet autoantibody assay

Anti-platelet membrane glycoprotein autoantibodies are positive and have high specificity for the diagnosis of ITP (primary immune thrombocytopenia)

3. Tests related to the diagnosis of coagulation factor deficiencies

coagulation cross-over test

Procoagulant activity of individual coagulation factors

Plasma fibrinogen (FIB)

Reference interval: 2.0~4.0g/L

clinical significance

Decreased fibrin

Primary fibrinogenopenia: congenital low or no fibrinogenemia, dysfibrinogenemia, rare

secondary fibrinogen reduction

Reduced synthesis: seen in cirrhosis and alcoholism

Excessive consumption:

primary hyperfibrinolysis

Due to hyperfibrinolysis, FIB is degraded, thus reducing

DIC (FIB is one of the diagnostic tests for DIC)

Due to coagulation, FIB is consumed

FIB is degraded due to hyperfibrinolysis

If it is a congenital or hereditary disease, genetic and other molecular biology testing should be performed to determine the precise nature and pathogenesis of its cause.

Diagnosis idea 2

1. Ask about medical history

Age of onset, bleeding triggers, bleeding locations and characteristics, accompanying symptoms and family history, etc.

2. Physical examination

On the basis of a comprehensive physical examination, pay attention to the location and characteristics of bleeding. For bleeding in various organs, the possibility of local lesions must be ruled out.

3.Laboratory and auxiliary examinations

Diagnostic Thrombosis Program

prothrombotic state

Screening Tests Common Tests

Primary hemostatic defects: PLT & BT

Both BT and PLT are normal.

Normal or mostly caused by vascular purpura caused by a simple increase in blood vessel wall permeability and/or fragility.

BT extension

Secondary hemostatic defects: APTT & PT

APTT and PT are normal.

Normal human or hereditary and acquired factor XIII deficiency

Abnormal APTT and PT

Hyperfibrinolysis: FDPs&D-D

FDPs and D-D are normal.

Indicates that fibrinolytic activity is normal and clinical bleeding symptoms may have nothing to do with fibrosis.

FDPs elevated, D-D normal

Most of them are false positives of FDPs, which are seen in liver disease, surgical bleeding, severe DIC, early fibrinolysis, after strenuous exercise, rheumatoid arthritis, the presence of anti-Rh(D) antibodies, etc.

FDPs normal, D-D elevated

Most of them are false negatives of FDPs, which are found in DIC, venous thrombosis, arterial thrombosis and thrombolytic therapy, etc.

Both FDPs and D-D are elevated

Indicates that fibrinogen and fibrin are degraded simultaneously, seen in secondary fibrinolysis, such as DIC and after thrombolytic therapy

special test

Thrombomodulin (TM) and/or endothelin-1 (ET-1)

Increased → reflects damage to vascular endothelial cells

P-selectin and/or 11-deshydrothromaxane B2 (11-DH-TXB2)

Increased → reflects platelet activation

Prothrombin fragment 1 2 (F1 2 ) and/or fibrinopeptide A (FPA)

Increased → reflects the enhanced activity of thrombin

Thrombin antithrombin complex (TAT)

Increase →Reflects enhanced thrombin activity

Plasmin Antiplasmin Complex (PAP)

Decrease →reflects decreased plasmin activity

Thrombophilia

arterial/venous thrombosis

DIC project

clinical diagnosis

There are underlying diseases that can easily induce DIC, such as multiple bleeding that cannot be explained by the primary disease, general skin and mucosal embolism, or organ failure such as brain, kidney, and lung, and anticoagulant treatment is effective.

Points diagnosis

Diagnosis of overt (decompensated) DIC

Diagnosis of non-overt (compensated) DIC