Pathology of

Bleeding Disorders:

Dr. Shashidhar Venkatesh Murthy

A/Prof. & Head of Pathology
 Learning Outcomes:
At the end of the session student will be able to,
Discuss normal hemostasis, how bleeding stops.
Discuss common bleeding disorders:
1. Common Blood Vessel disorders.
2. Common Platelet disorders.
3. Common Coagulation disorders.
4. Hypercoagulability/Thrombophilia disorders.
Discuss Pathology of each:
Clinical features, Pathogenesis & Laboratory diagnosis.

Top Disorders:
Thrombocytopenia, ITP.
Vit-K deficiency.
Heparin, Warfarin, Aspirin
Less More Cong: Haemophilia, VWD
Bleeding Disorders - Clinical
Normal Hemostasis Components:
1. BV Vasoconstriction
2. Platelet plug formation
3. Activation of Coagulation stable fibrin plug.
4. Activation of fibrinolysis clot dissolution.

Injury

BV spasm

Plt. plug.
Fibrinolysis

Coagulation
 Haemostasis overview:
Injury

BV Injury BV spasm

PLt. Act.

Blood Vessel Platelets Plasma

Coag.

BBlood Vessel
Cloonosdtricvtieosnsel DisoPlradteelertsof Coagulation
APgglraetgeatlieotns CoagCuaslcaatdieon
Primary hemostatic plug

Reduced Platelet Fibrin

Blood flow Activation formation*

D i so r d er s D i so rd e rs
Ant ico ag u la nts
Thrombophilia
Stable Fibrin Plug FiFibrinolysis
br i n o ly sis
 LAB TEST:
LAB TEST: PT ~10 sec.
aPTT ~20 sec. Prothrombin
Activated Partial Time. Factor 7
Thromboplastin Time.
Factor 12, 9, 8

Bl. Clot
 What actions are most excellent?
To gladden the heart of a human being,
to feed the hungry, to help the afflicted to
lighten the sorrow of the sorrowful and to
remove the wrongs of injured...
- Dr. APJ Abdul Kalam.

This is the reason medical profession is considered special!

 Clinical bleeding symptoms:
Petechiae <3mm Blood Vessel / Platelet disorder

Purpura <1 cm

Echymosis >1cm

Hematoma

Key Words:
Hemostasis
Primary plug
Sec. / stable plug
Blood clot.
Plt. Aggregation.
Plt. Adhesion
Plt. Activation
Trauma / Coagulation Coagulation
Thrombosis
Thrombolysis
Thrombophilia
Superficial Deep Bleeding/
Platelet / BV Coagulation

Superficial & small Platelet & BV disorder .A

Deep & Big Coagulation disorder .B
Good and Evil, happiness and misery, merit
and sin depend on our actions. As is the
action so is the result. It is easy & fun to
indulge in sinful deeds but it is extremely
painful to bear the bad results they yield.
Karma You reap what You sow.. .
Sai Baba
 Bleeding Disorders: Classification
Blood Vessel Platelet Coagulation
Constriction Aggregation Cascade
Blood Vessel Disorders: Platelet Disorders: Coagulation Disorders:
Hereditary Function disorder Hereditary:
H.H.telangiectasia Drugs Aspirin Haemophilia A, B
Marfans sy. Kidney failure: uremia. Von Willebrands
AcquirBleeding Thrombocytopenia: Acquired:
Disorders: Immune - ITP Liver disease.
Classificationed Drugs, viral Infection Drugs - Heparin.
Simple easy bruising Aplastic anemia. Inhibitors immune.
Aging,Scurvy, Chemotherapy. Blood Transfusion
Drugs - steroids
Viral infections.
DIC Disseminated Intravascular Coagulation All factor deficiency Septicemia
Thinking should become
your capital asset, no matter
whatever ups and downs you
come across in your life.
- Wings of Fire: An Autobiography of Dr. APJ Abdul Kalam.
 Disorders of Haemostasis:
Blood vessel & Platelet disorders

Shashidhar Venkatesh Murthy

B.Sc, MBBS, MD(path), GCTT, MBA(Edu), IFCAP(USA)
A/Prof. & Head of Pathology
Dengue Hemorrhagic fever BV & Plt

Purpura in viral infections:

Direct vascular damage,
immune vasculitis leading to
platelet activation &
Coagulation.
Thrombocytopenia: Commonest bleeding.
Immune, Bone marrow dis, drugs, infections, Spleen
Spleen
Bone Marrow Circulation
Coag.
 ITP: Immune Thrombocytopenic Purpura.
Autoimmune disorder.
IgG Ab against plt. Mem. glycoproteins.
Destroyed in Spleen. Thrombocytopenia, giant plts. Acute ITP: Petechiae

easy bruising.Insidius onset, Petechiae, purpura,

Acute & Chronic types.
Acute (children, post infections)
Autoimmune)Chronic (females, 20-40y,
Platelet counts & bone marrow examination.
BM: Increased Immature megakaryocytes.
Blood: Thrombocytopenia with giant platelets.
Other hemostasis tests normal.

Chronic ITP: Female 28y.

 Vit-K Deficiency:
Green Veg & Intestinal bacteria.
Deficiency of 2,7,9 & 10, C & S.
Diet, Drugs & Liver Disease
Warfarin *
Lab: PT. Normal PTT (F7)

Factors: 2,7,9,10

Warfarin
 Von Willebrand Disease: Plt & F VIII

Commonest Cong. Bl. Disorder.

Autosomal recessive (M:F)
Deficiency of vWF & F VIII*
Both Plt & Coag. Disorder.
Type-1 85%, Quantitative, mild.
Type 2 Qualitative, rare.
Type 3 total absence, rare.
Easy bruising & muco-cutaneous
bleeding. Petechiae, Purpura.
Lab Diagnosis:
Prolonged bleeding time &
normal coagulation time
(mild F8 def.).
Normal platelet count.
 Haemophilia-A
Mod 1-5%
X linked. Xq 2.8, Factor VIII def.
Males affected, Female carrier.
Factor level of >30% normal.
Factor level <1%, 1-5%, >5% mild
Wound bleeding & Hematoma.
Mild >5%
aPTT prolonged PT normal,
FVIII assay. Treat: FVIII.
Haemophilia B: similar, F IX def.
Chronic deformity

Severe <1%
 DIC: Disseminated Intravascular Coagulation.
Excess whole body activation of hemostasis
Consumption of factors Bleeding.
Cause / Etiology: (infection, trauma, cancer)
Tissue factor release into circulation - trauma
Or Widespread endothelial damage - infection
Morphology / Clinical features:
Thrombosis, Severe bleeding, shock, renal failure.
Laboratory Diagnosis:
All tests abnormal*
To educate a person in the mind but not in
morals is to educate a menace to society.
-Theodore Roosevelt
Anticoagulants &
Hypercoagulability Disorders.
 Warfarin
Warfarin

Heparin

Bl. Clot
 Arterial thrombosis
Thrombophilic disorders: Thromboembolism
Venous thrombosis
Hereditary: Abortions.

Factor V Leiden (resistant to breakdown)

Protein C or S deficiency (anticoag.).
Prothrombin Gene mutation (hyperact.)
Acquired:
CVS disorders MI, DM, HPTN.
Major trauma or inflammation or
malignancy procoagulants.
Drugs - Oestrogen therapy.
Hyperhomocyteinaemia (rarely hereditary)
Antiphospholipid syndrome.
Lupus anticoagulant & Anti cardiolipin Ab.
Intelligence plus character, that is the
goal of true education
- Martin Luther King Jr.
Students today enticed by modernity,
have become oblivious to their
identity & purpose in life.
In order to succeed, your desire for
success should be greater than your
fear of failure.
- Bill Cosby
To educate a person in the mind but not in
morals is to educate a menace to society.
-Theodore Roosevelt
What you admire in others will develop in
yourself. Therefore, to love the ordinary
in any one is to become ordinary, while
to love the noble and the lofty in all is to
grow into the likeness of that which is
noble and lofty.
Christian Larson
 Why only PT abnormal in Vit-K def?
Vit-K Liver Coag. Factors 2,7,9,10 both PT & aPTT should raise?

Ans: Shortest half life!

Why no effect?