Coagulopathy and Bleeding Disorders - Differential Diagnosis

1° hemostasis (↓ platelet # or function, VWD → mucocutaneous bleeding, petechiae) or 2°(prolonged PT/PTT → deep tissue bleeding)

Rule out artifact, anticoagulant use, or systemic disease (cirrhosis, DIC, abx, malnutrition, renal dz, cancer)

If prolonged PT / PTT and etiology is not clinically apparent, order mixing study w/ normal plasma

 • If PT / PTT corrects: supports clotting factor deficiency (confirm w/ factor specific assays)

 • If no (or partial) correction: supports presence of inhibitor (confirm w/ inhibitor specific assays)

    o Drug inhibitor (e.g. heparin), acquired factor inhibitor (VIII, V>>IX, XI), nonspecific inhibitor (e.g. LA)

 • If work-up is unrevealing, think VWD, platelets, can check FXIII (most commonly presents w/ delayed surgical bleeding)

Tx: replace missing factor, eliminate inhibitor (immunosuppressants), treat underlying condition

Normal PT, Normal aPTT:

 • Platelet dysfunction (VWD, other platelet disorders)

 • ↓ Factor XIII

Normal PT, Prolonged aPTT - Intrinsic pathway: 

 • ↓ Factor VIII, IX (hemophilias), or XI (Ashkenazi)

 • VWD (↓ factor VIII)

Prolonged PT, Normal aPTT - Extrinsic pathway:

 • ↓ Factor VII (liver, congenital, early DIC)

 • Vit K deficiency/warfarin

Prolonged PT, Prolonged aPTT - Common pathway:

 • Liver, DIC, warfarin OD/rat poison

 • Rarely common pathway deficiency/inhibitor



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