Practical Approach to the Bleeding Patient
Urs Giger, Diplomate ACVIM & ECVIM
Veterinary Hospital, University of Pennsylvania
Philadelphia, PA, USA
P: 1 215 573 6109 office
F: 215 573 2162
Bleeding is a common clinical presentation in small animal practice. Bleeding disorders occur more commonly in dogs than in cats. Clinical manifestations of bleeding disorders may range from mild and self-limited to life-threatening hemorrhage requiring immediate medical attention. Animals may bleed due to vascular injury caused by any trauma, surgery, ulcer, and tumor. In case of hemostatic disturbances, the hemorrhagic tendency is exaggerated as exemplified by spontaneous, multifocal, and unexpected severe bleeding.
Hemostasis is the complex physiologic response to bleeding and can be divided into primary and secondary hemostasis. Vascular endothelium, platelets, and von Willebrand factor (vWF), are required for primary hemostasis or the formation of the unstable platelet plug, which is sufficient to stop capillary bleeding. Von Willebrand factor, a large plasma protein synthesized by endothelium facilitates adhesion between platelets and subendothelium. With larger vessel injury, coagulation factors are also needed to form a stable fibrin clot known as secondary hemostasis. Hemostatic disorders can be conveniently classified into vasculopathies, thrombocytopenias, thrombopathies, von Willebrand disease (vWD), and coagulopathies realizing that some disease processes cause combined hemostatic defects (e.g., disseminated intravascular coagulopathy [DIC]). Hemorrhagic presentations may suggest certain hemostatic disorders and practical tests are available to characterize the bleeding tendency. An accurate diagnosis of the cause of bleeding will influence the treatment and outcome of a patient.
The coagulation cascade is a series of enzymatic reactions involving coagulation factors, denoted by Roman numerals. This complex biochemical pathway plays three pivotal roles in the formation of fibrin from fibrinogen:
Coagulation factors are enzymes (serine proteases), cofactors, or substrates of particular reactions of the coagulation cascade. Most factors are given roman numerals from I-XIII, but the numbering is not sequential and there is no factor VI. Calcium (factor IV) is required for most reactions and is the reason why chelators, e.g., citrate and EDTA, are used for blood collection and processing, where plasma or blood cells are analyzed. All glycoproteins of the coagulation cascade are synthesized in the liver and circulate as inactive precursors in the plasma. They need to be activated at the site of vessel injury (depicted with letter a following their Roman numeral). Vitamin K is needed for the functional synthesis of the coagulation factor II, VII, IX, and X. The half-lives of the coagulation factors varies from hours (Factor VII) to a few days (Fibrinogen). It should be noted that in vitro coagulation factor interaction, known as clotting, proceeds somewhat differently from the above described in vivo coagulation cascade, but is helpful in identification of specific coagulopathies. Following a fibrin plug formation, plasminogen will be activated and plasmin, an unspecific protease will commence breaking down fibrinogen as well as fibrin which results in fibrinogen lysis and fibrin(-ogen) split product (FSP) as well as D-dimer formation.
Signalment & Family History-Although hereditary coagulopathies may occur in any breed, each coagulopathy has thus far only been reported in certain breeds. Hemophilia A and B occur in many different breeds and are X-chromosomal recessively inherited; thus, only males are generally affected and females are asymptomatic carriers. Signs of bleeding typically occur at an early age and are often recurring, but may not be recognized until adulthood.
History-Bleeding may be induced (trauma, surgery) or appear spontaneous. Careful history taking may reveal exposure to toxins (rodenticides, mushrooms) and drugs (warfarin, heparin). It is important to identify the specific product, as e.g., different rodenticides have quite varied potency. Any evidence of other diseases, e.g., hepatopathies and cancer, may be responsible for the hemorrhage.
Physical Examination-Careful clinical evaluation may differentiate between primary and secondary hemostatic defects. Surface bleeding is typically seen with primary hemostatic disorders. Petechia and ecchymosis are hallmark features of thrombocytopenias and thrombopathies. Von Willebrand disease is causing bleeding at sites of injury (trauma, dental disease, estrus, gastrointestinal) rather than petechia or ecchymosis. Coagulopathies may be associated with single or multiple sites of bleeding characterized by cavity bleeding such as hematoma, hemarthrosis, hemomediastinum, and hemoperitoneum and-thorax, but gastrointestinal hemorrhage and bruising may also occur. Signs of other underlying diseases may be recognized.
Hemostatic tests are indicated
Primary Hemostasis: Platelets & vWF
Since 8-15 platelets are normally found per high power oil emersion microscopic field, an absence to low number of platelets suggests a severe thrombocytopenia. Hemorrhage is generally not observed unless the platelet count is <40,000/µl (normal 150-500,000/µl). Detection of platelet-associated antibodies further supports an immune-mediated thrombocytopenia, but this test is rarely available. Serum titers for Ehrlichia canis and platy are indicated in certain states and countries. The presence of schistocytes and thrombocytopenia suggests intravascular disseminated coagulation, where intravascular fibrin strands fragment erythrocytes. Because von Willebrand disease is such a common mild primary hemostatic defect in dogs, plasma vWF measurements by ELISA are indicated. Alternatively, DNA testing is available in some canine breeds for specific vWD-causing mutations and is useful for detection of carriers. Finally, in light of normal platelet count and plasma vWF values, a prolonged buccal mucosal bleeding time (BMBT) indicates a thrombopathy. Disposable devices are available that facilitate making 1-2 standard 1mm deep mucosal incisions. The platelet function analyzer (PFA100) is a simple tool to functionally assess primary hemostasis. Electron microscopic and platelet aggregation and nucleotide studies allow further characterization of platelet dysfunctions in specialized laboratories.
Secondary Hemostatic Tests: Coagulation Tests
Whereas the whole blood clotting time test is insensitive and inaccurate, there are several standardized coagulation screening tests that are useful to define coagulopathies in clinical practice. The screening tests assess coagulation in vitro, which is helpful, but is now known not to be identical with the in vivo coagulation process. Nearly all coagulation tests assess the function of certain parts of the coagulation system in fresh whole blood or fresh (frozen) plasma to generate fibrin in a fibrometer; recalcified citrated plasma is used and many tests are comparing a patient sample directly with a simultaneously obtained control or pool plasma (plasma from 10 animals). Generally coagulation times, the time to clotting (fibrin formations), are much shorter in small animals than in humans; thus, tests need to be validated for the animal species.
The intrinsic and common pathways are assessed by either the activated coagulation time (ACT) or activated partial thromboplastin time (PTT). Factor XII of the intrinsic cascade is activated by diatomaceous earth (celite) in the ACT test and by kaolin or other contact phase substrate in the PTT test.
The extrinsic and common pathways can be assessed by either the prothrombin time (PT) or the protein induced by vitamin K antagonism or absence (PIVKA) test. Different tissue factors (thromboplastins) are activating factor VII, which in turn will lead to fibrin formation. It should be noted that the PIVKA test is not specific for the detection of anticoagulant rodenticide poisoning, but detects any coagulation factor deficiency of the extrinsic and common pathway and is therefore not that helpful.
Until recently the ACT tube test and PIVKA tests were the only point of care tests available for clinical practice, whereas PTT and PT tests were performed in reference laboratories. There are now new point of care coagulation instruments (e.g., SCA2000) introduced that are capable of determining without delay on small amounts (50µl) of fresh citrated whole blood the PTT and PT, thereby making the chilling, rapid separation of citrated plasma and shipment of frozen plasma on dry ice to the laboratory for initial coagulation screening unnecessary.
In fact, a reasonable and simple approach for a bleeding animal to be screened for a coagulopathy would be to measure the ACT or PTT first as either test detects all coagulopathies (except for hereditary factor VII deficiency in Beagles). If the PTT (or ACT) is prolonged, a PT test would be indicated to differentiate between an intrinsic and common pathway defect or a combined coagulopathy involving several coagulation factors.
Although hereditary coagulopathies can be suspected based upon the pattern of coagulation test abnormalities, specific factor analyses are needed to confirm a diagnosis. A bleeding male animal with a prolonged PTT (or ACT) and normal PT likely has hemophilia A or B (factor VIII or IX deficiency), an X-chromosomal recessive disorder. However, factor XI deficiency is associated with the same test abnormalities and is inherited by an autosomal recessive trait (e.g., Kerry blue terriers). Finally, factor XII deficiency, particularly common in domestic shorthair cats, and prekallikrein deficiency causes marked PTT (ACT) prolongations but no excessive bleeding tendency.
Rodenticide poisoned animals that are bleeding or are at risk for bleeding will have prolongations in all of the above coagulation tests, but would have a normal thrombin time (TT). The thrombin time is independent of vitamin K-dependent coagulation factors and is a functional assay for fibrinogen to form fibrin. A toxicological investigation (product identification, blood toxicology analysis) may confirm the rodenticide poisoning. Moderate thrombocytopenia may be associated with warfarin type-rodenticide poisoning.
All liver diseases may result in varied coagulopathies due to impaired coagulation factor synthesis and vitamin K malabsorption. Similarly, disseminated intravascular coagulopathies (DIC), due to many different disorders is associated with variably prolonged coagulation times. More helpful to the diagnosis of DIC are the recognition of schistocytes, thrombocytopenia, low antithrombin III levels, and increased D-dimers and fibrin split (degradation) products. Recently a simple kit for canine D-dimers (Agen) has become available.
Therapy and Monitoring
The coagulation tests are also useful to monitor therapeutic interventions. Heparin drastically prolongs the PTT/ACT and to a much lesser extent the PT. In contrast, warfarin causes PT and PTT prolongations like the anticoagulant rodenticides. Thus, heparin and warfarin anticoagulant therapy are monitored by PTT (ACT) or PT, respectively. Similarly, vitamin K therapy (<5mg/kg/d po or sc) should correct vitamin K deficiency states and can be assessed by either PT or PTT measurements.
Animals with thrombocytopenia are rarely treated with platelet transfusions except with life-threatening hemorrhage. Platelet transfusions via fresh whole blood will increase the platelet count by 20,000/ul per 10 ml blood per kg body weight. They may receive glucocorticoids and doxycycline as ehrlichiosis and immune-mediated thrombocytopenia are the most common causes of thrombocytopenia in dogs.
The effect of transfusion support in bleeding animals with coagulopathies is also evaluated by coagulation screening tests and PCV. Fresh frozen plasma (10 ml/kg every six hours) is appropriate for all coagulopathies, whereas cryoprecipitate (2-5ml/kg) is useful for control of bleeding in hemophilia A and von Willebrand disease. In addition, packed red cells or fresh whole blood alone could be used to correct the associated anemia.
In order to best assess the patient's changes in the ability to coagulate, it is important to use the same technique and ideally same operator/laboratory. These above described simple guidelines should assure the correct diagnosis and successful management of animals with hemorrhage.
A search for an underlying disorder should also be pursued.
* Use veterinary laboratories established reference range.
SCA 2000 instrument using fresh citrated whole blood.
Giger, U: Practical Guide to the Diagnosis of Coagulopathies, Synbiotics, 2000.
Urs Giger, ACVIM & ECVIM