Evaluation and Management of Unexplained Bruising in Adults

Initial Evaluation and Testing

The American Society of Hematology recommends immediate bleeding tests for unexplained bruising without trauma in adults, as it may indicate an acquired bleeding disorder, such as acquired von Willebrand syndrome or other coagulopathies 1
Initial laboratory evaluation should include a complete blood count (CBC) to assess platelet count, prothrombin time (PT) to evaluate the extrinsic coagulation pathway, activated partial thromboplastin time (aPTT) to evaluate the intrinsic coagulation pathway, and von Willebrand factor testing 1
Von Willebrand factor testing is critical because VWF disorders are not reliably detected by PT/aPTT alone, according to the American Society of Hematology 1, 2

Acquired von Willebrand syndrome (AVWS) should be strongly considered in adults presenting with new-onset bleeding symptoms without personal or family history of bleeding disorders, especially in those with underlying medical conditions 1
Other acquired coagulopathies, such as acquired factor deficiencies and platelet dysfunction disorders, may present with spontaneous bruising and abnormal aPTT 3, 4
Vitamin K deficiency and liver disease are less likely but should be considered, as they can cause prolonged PT and aPTT 1, 4

Normal PT and aPTT do not rule out a bleeding disorder, as von Willebrand disease is frequently missed due to normal standard coagulation tests 2
Mild factor deficiencies and platelet function disorders may not prolong aPTT and require specialized testing 4, 5
Von Willebrand factor is an acute phase reactant, and levels can be falsely elevated during stress or illness, so repeat testing may be necessary 2

Consultation with hematology should occur if initial screening tests show abnormalities, bleeding symptoms persist despite normal initial testing, or additional specialized testing is needed 1, 5
A complete medication review, review of systems, and physical examination should be documented to evaluate for signs of systemic disease and other potential causes of bleeding 3, 4