Bleeding can also occur spontaneously under the skin, in joints and internal organs without any recognizable cause. Typically, bruising, nosebleeds and bleeding gums also occur more easily and frequently. An increased tendency to bleed can be a symptom of various diseases. However, it can also occur as a side effect of medication. The main causes are diseases of the blood platelets (thrombocytes), blood vessel diseases or a blood clotting disorder. In each of the cases mentioned, the bleeding tendency can be either congenital or acquired.
After operations, childbirth or injuries, there is a risk of post-operative bleeding.
What is a bleeding tendency?
A bleeding tendency can have various causes. The most common cause is a hemostasis disorder. Hemostasis is important so that bleeding wounds can be closed. In healthy people, it is only activated if there is also a vascular injury.
The best-known form of a blood clotting disorder with an increased tendency to bleed ishemophilia. This is almost always genetic. Those affected, usually men, lack coagulation factors in their blood. Although hemophilia is so well known, it is comparatively rare.
Hemostasis disorders occur much more frequently as a side effect of certain diseases or as a side effect of certain medications.
Fortunately, severe forms of a bleeding tendency are very rare. Mild forms are often not even noticed by those affected and are sometimes only noticed during routine examinations or when unusual bleeding occurs during surgery.
Bleeding tendency: Causes and risk factors
Bleeding tendencies are much more frequently acquired than congenital. In most cases, acquired bleeding disorders are due to medication that impairs the function of the blood platelets or disrupts blood clotting. Congenital bleeding tendencies occur with a frequency of 1:200 in the population.
Bleeding tendency due to a blood clotting disorder
The blood coagulation system is very complicated. On the one hand, the blood must not clot at an injured site, otherwise there is a risk of vascular occlusion. On the other hand, haemostasis and coagulation must function after an injury in order to stop the bleeding. The right balance is important to ensure that clots are formed, localized to where they are needed and then dissolved again. This requires many different coagulation factors, blood cells and messenger substances.
Primary hemostasis ensures that a leak in a blood vessel is temporarily sealed by a clot. The platelets clump together to form a clot, but this is unstable and only lasts for a few minutes.
In secondary hemostasis (blood clotting), the clot of blood platelets is permanently sealed with the help of fibrin, which is formed by the action of the plasma enzyme thrombin.
Both processes can be disturbed. This is either because components that activate hemostasis or coagulation are missing. Or because there are too few platelets or they are not functioning properly (see next chapter, Platelet disorders). Or because autoantibodies block the effect of certain hemostasis components.
A blood clotting disorder can be caused by
- Side effects of medication such as heparin, anticoagulants, painkillers such as aspirin, cortisone or antibiotics
- Pronounced liver dysfunction, as many coagulation factors are formed there
- Vitamin K deficiency (some coagulation factors are formed depending on vitamin K)
- Von Willebrand syndrome: the most common congenital cause of a bleeding tendency. This is due to a deficiency or dysfunction of a plasma protein, the von Willebrand factor, which plays an important role in hemostasis.
- Hemophilia: Hemophilia is a comparatively rare congenital form of bleeding disorder in which blood clotting is impaired. It is inherited in a sex-linked manner, so that those affected are men; women can transmit the condition (female conductors).
Tendency to bleed due to a disorder of the blood platelets (thrombocytes)
Platelets are an important component of hemostasis. If a blood vessel is injured, they clump together and form a clot (thrombus) that closes the wound. If there are too few platelets or they do not function properly, this results in an increased tendency to bleed.
Platelet disorders can be caused by
- Platelet deficiency (thrombocytopenia): This can be caused, for example, by infections, an enlarged spleen, alcohol abuse, pregnancy or certain medications such as ibuprofen or heparin. An autoimmune disease in which the immune system attacks the blood platelets (immune thrombocytopenia) can also be the cause.
- Functional disorders of the blood platelets (thrombocytopathy): The number of blood platelets is often normal, but they do not function properly. This is often caused by medication, but also by diseases such as leukemia (blood cancer) or congenital platelet dysfunction.
Bleeding tendency due to vascular diseases
If the blood vessels are pathologically altered so that they are less stable than normal, the tendency to bleed can also increase. Diseases that lead to this can be both hereditary and acquired and can affect the entire vascular system as well as individual sites.
One example of a hereditary disease is Osler’s disease. In this rare disease, the blood vessels are dilated to form small clusters (telangiectasias) and are therefore very vulnerable. For this reason, bleeding occurs quickly. However, congenital blood vessel diseases as the cause of a bleeding tendency are rare overall.
However, older people often have “senila purpura”. The smallest blood vessels have become fragile. They allow blood to pass through, which then collects under the skin, especially on the back of the hand and on the forearms. These bleedings are harmless and disappear again. However, they can leave darker spots.
Blood vessel diseases can be caused by
- increased vascular permeability in old age or after long-term cortisone therapy
- a weakness of the vascular connective tissue due to vitamin C deficiency (scurvy)
- Congenital vascular changes
Bleeding tendency: symptoms
There are both mild forms of bleeding tendencies, which are sometimes only noticed during routine examinations or unusually pronounced bleeding during procedures, and severe to life-threatening forms.
The WHO has defined different degrees of severity for bleeding. Grade one indicates a minimal tendency to bleed, grade four a life-threatening one.
What all forms of bleeding tendency have in common is that bleeding lasts too long, is too heavy or arises from a trivial cause. Depending on the cause, however, there are other typical symptoms.
Tendency to bleed: General symptoms
- Heavy and unusually prolonged bleeding even after minor injuries
- Frequent nosebleeds
- Frequent bleeding gums
- Frequent bruising even after minor bumps
- Spontaneous bleeding under the skin, in joints or internal organs
- Increased and prolonged menstruation
Bleeding tendency: Special symptoms
- In vascular diseases and as a side effect of cortisone: frequent bruising, especially on the forearms and hands
- in the case of disorders of plasmatic blood coagulation: extensive bruising (here the tendency to spontaneous bleeding in soft tissue, joints, etc., see above)
- platelet deficiency: bruising, mucosal bleeding and pinhole-sized hemorrhages in the skin that do not disappear when you press on them (petechiae)
- In the case of platelet dysfunction or von Willebrand syndrome: bruising, mucosal bleeding, petechiae, nosebleeds and heavy menstrual bleeding
When should you visit us?
If you suspect a bleeding tendency, you should always come to us.
A suspicion exists if:
- you notice bruises more frequently or more pronounced than before and do not know where they come from
- you frequently have nosebleeds or bleeding gums
- you have unusually heavy menstruation
- you notice punctiform hemorrhages (petechiae) on the skin and mucous membrane
- unusually heavy bleeding has occurred after tooth extractions, operations or births
- You have a family history of a tendency to bleed, which you should also have checked (e.g. before an upcoming operation)
- bleeding cannot be stopped (in this case you should contact us immediately)
Bleeding tendency: Diagnosis
First of all, it is important to ask the patient structured questions about their bleeding history (medical history).
These include, for example:
- Do you suffer from frequent nosebleeds?
- Do you bruise easily?
- Do you have the impression that wounds bleed for a long time?
- Did unusual bleeding occur in connection with tooth extractions, operations or births?
- What medication are you taking?
- Are there cases of increased bleeding tendency in the family?
Depending on the suspicion, a hemorrhagic diathesis can be determined by means of a blood test. First of all, we have the number of platelets in the blood determined in the laboratory and coagulation tests (Quick/INR, aPTT and thrombin time) carried out. The values indicate how quickly the blood coagulates. It is important that the person concerned refrains from taking blood-thinning medication such as aspirin in consultation with us before the blood test.
Vascular damage can usually be detected relatively easily using the Rumpel-Leede test. We place a blood pressure cuff on the upper arm and pump it up to 10 mmHg above the diastolic blood pressure. If the vessels are fragile, pin-sized skin hemorrhages (petechiae) appear after five minutes.
However, a more extensive blood test must be carried out in special coagulation laboratories in order to determine a functional disorder of the blood platelets or a deficiency of certain coagulation factors. If a disorder of platelet formation is suspected, a bone marrow examination may also be necessary.
Tendency to bleed: Prevention and prognosis
Since a bleeding tendency can have different causes and can occur in different degrees of severity, it is not possible to make a uniform statement about the course and prognosis.
It is important to find the cause of the increased bleeding tendency. If this can be eliminated, the bleeding tendency as a symptom also disappears. For example, if an increased tendency to bleed is a side effect of a medication, it will disappear when the medication is discontinued. If the cause is an underlying disease such as leukemia, this must be combated. There are also hereditary diseases such as haemophilia or von Willebrand syndrome, which cannot be cured as yet. An important aim here is to draw up recommendations for operations, tooth extractions, childbirth or other risk situations in order to prevent the occurrence of bleeding. Patients with serious congenital disorders of hemostasis such as haemophilia or severe forms of von Willebrand syndrome are generally cared for by us on a long-term basis and regularly invited for follow-up checks. We also offer innovative therapies for such disorders.
Even though some diseases associated with a tendency to bleed cannot be cured, they can be treated. As a rule, an almost normal life is possible. However, it is important to take appropriate precautions.
If you know that you have an increased tendency to bleed, you should minimize your risk of injury by avoiding certain sports with a high risk of injury and training your dexterity and balance.
