Bruising (ecchymosis) results from the extravasation of blood beneath intact skin, most often due to trauma.

• When discordant with the degree of trauma may be caused by an underlying bleeding disorder.^1,2
• Up to 55% of otherwise healthy individuals will present with easy bruising.^1,2

Major etiologies of bruising include:^1,2

• Trauma: accidental, non-accidental.
• Vascular disorders: senile purpura, simple purpura, connective tissue diseases, vitamin C deficiency.
• Platelet disorders: immune thrombocytopenia, thrombotic thrombocytopenic purpura, aplastic anemia, hematologic malignancies, congenital/inherited platelet disorders.
• Coagulation disorders: Von Willebrand disease, hemophilia A, hemophilia B, liver disease, vitamin K deficiency.
• Drugs: alcohol, corticosteroids, aspirin, NSAIDs, clopidogrel, SSRIs, certain antibiotics, thiazide diuretics, warfarin, heparin, DOACs.

History

• Consider relevant medical conditions, medications, social history, and family history.^1,2,3
• Consider including a specific bleeding/bruising history. The International Society on Thrombosis and Hemostasis Bleeding Assessment Tool may be used to guide questioning.^1,2,3
• Rule out abuse in pediatric, geriatric, and vulnerable populations.
• Red flags for bruises associated with physical abuse include:^1,2,3
  • Bruises discordant with the given explanation.
  • Bruises on not yet mobile children.
  • Bruises on torso, buttocks, ears, or neck.
  • Bruises that are large, numerous, clustered or patterned in the shape of a striking implement.

Physical

• Bruises location, size, shape, number, etc., joints, abdomen, head, neck, and lymph nodes.
• Normal bruises tend to be small, relatively round, have non-distinct borders, and appear over bony prominences on the anterior surface of the body.^1,2
• Bruises indicative of an underlying bleeding disorder may be persistent, spontaneous, numerous (>5), large (>1cm), or appear in abnormal locations (e.g. trunk, back, and face).^1,2
• Mucocutaneous bleeding suggests vasculature, Von Willebrand factor, or platelet disorders.^1,2
• Petechiae suggests severe thrombocytopenia.^1,2,3
• Purpura suggests thrombocytopenia or vasculature disorders.^1,2
• Hemarthroses or muscle hematomas are indicative of coagulation factor disorders (e.g. hemophilia).^1,2,3
• Joint or skin laxity may indicate a connective tissue disorder.^1,2,3
• Hepatosplenomegaly may indicate liver or systemic disease.^1,2,3

Laboratory Investigations

include:^1,2,3

• Complete blood count (CBC) with differential.
• Prothrombin time (PT) or international normalized ratio (INR).
• Activated partial thromboplastin time (PTT).
• Liver, renal, and thyroid function tests.

Bruising with no suspicion of an underlying bleeding disorder can be treated with simple analgesia (acetaminophen, ibuprofen, etc.) and patient reassurance.²

• Clinically stable patients with continued unexplained bruising/bleeding, with or without abnormal laboratory investigations, should be referred to a hematologist.² Urgency relies on clinical judgment of severity.
• Admit patients with significant active bleeding that is unresponsive to initial management (e.g. compression).² Admit vulnerable patients if abuse is suspected; abuse should be reported to the appropriate government agency.²
• Medications suspected to be causing bruising should be discontinued, if possible.²

1. Assessment of easy bruising. 
   Wang TF, Kraut, EH.  2018. Accessed 5 June 2021.
   BMJ Best Practice.

   
   

2. Clinical Knowledge Summaries (CKS)—Bruising.
   National Institute for Health and Care Excellence (NICE) Accessed 5 June 2021.

   
   

3. Clinical Evaluation of Bleeding and Bruising in Primary Care. Am Fam Physician.
   Neutze D, Roque J.  2016;93(4):279-86.
   PMID: 26926815.

   
   

4. Bleeding Assessment Tool.
   ISTH-SSC