The International Working Group on ITP has developed a consensus-based bleeding assessment tool inclusive of standardized definitions of bleeding, a symptom-specific and domain-specific grading and a harmonized standardized questionnaire for adults and children.
Bleeding signs/symptoms are grouped according to three major domains: Skin (S), visible Mucosae (M) and Organs (O).

Skin (epidermis, dermis and subcutaneous tissues) includes Petechiae, Ecchymosis (purpuric macula, bruise or contusion), Subcutaneous hematomas, Bleeding from minor wounds.

Visible Mucosae include Epistaxis, Oral cavity (gum bleeding, hemorrhagic bullae/blisters, bleeding from bites to lips & tongue or after deciduous teeth loss/extraction), Subconjunctival hemorrhage.

Organs include GI bleeding (hematemesis, melena, hematochezia, rectorrhagia), Lung bleeding (hemoptysis), Hematuria, Menorrhagia, Muscle hematoma, Hemarthrosis, Ocular bleeding, Intracranial (intracerebral, intraventricular, subarachnoidal, subdural, extradural).

Gradation of bleeding severity (SMOG system): Each bleeding manifestation should be assessed at the time of examination. Its severity is graded from 0 to 4 (see example in table). Appreciation of bleeding based on history only, without supporting medical documentation, will be given a grade 1 designation. Within each domain, the same grading is assigned to the symptoms judged to have similar clinical relevance. For each symptom, the worst ever episode during the observation period is graded and then the worst episode within the domain is recorded. For example if the highest grade is 2 for skin, 3 for mucosae and 2 for organs, SMOG is S2M3O2. The index produced by summing the worst ever grade in the 3 domains represents the final score for that particular patient. In the example shown, the final score is 7. However, it is immediately appreciated that O2 has a much higher clinical impact than S2, so that a different weight (to be determined by ad hoc prospective studies) should be attributed to the different domains. 4. Questionnaire, harmonized to the different bleeding manifestations and their grading, to facilitate the allocation of each symptom and its severity.


Data collection form

Grading table

Examples of bleeding manifestations

For comments and suggestions please contact rodeghiero@hemato.ven.it