Download - Deep vein thrombosis
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Deep vein thrombosis
David Hughes
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Pathophysiology
• normal deep pelvic/leg veins• thrombus (red cells, fibrin) around valves• propagation• Virchow’s triad (endothelium, coagulability,
stasis)
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Symptoms
• asymptomatic• warm, red, swollen leg• unilateral pain, improved by elevation• gradual onset• superficial venous distension• pitting oedema• mild fever• tachycardia
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Wells criteria
• active Ca (Rx last 6/12 or palliative) +1• calf swelling >3cm compared to other calf +1• distended non-varicose superficial veins +1• pitting oedema +1• previous DVT +1• swelling of entire leg +1• localised pain along deep venous system +1• paralysis/paresis/recent cast immobilisation lower limbs +1• recently bedridden > 3/7 or major surgery in past 4/52 +1
• alternative diagnosis at least as likely -2
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Wells interpretation
• ≥2 - DVT likely, consider imaging leg veins• <2 - DVT unlikely, consider D-dimer to further
rule out DVT
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Other predisposing factors
• age (>40)• smoking• obesity• pregnancy• oral contraceptive• HRT• thrombophilia• long-distance flight• cardiac failure• dehydration
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Prophylaxis
• early mobilisation• elevation of legs• compression stockings• LMW heparin• weight loss
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Differential diagnosis
• cellulitis• ruptured Baker’s cyst
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Investigation
• calf circumference (calf >3cm than other 10cm below tibial tuberosity)
• D-dimer (not diagnostic, suggestive but not conclusive)
• Homan’s sign ill-advised• Doppler ultrasonography (iliofemoral)• venography (definitive, calf)
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Treatment
• bed rest initially• elevate leg• analgesia• compression stocking (post-thrombotic)• anticoagulation• Rx-dose heparin (1.5mg/kg/24h SC)• warfarin for 3-6/12 (INR 2-3)• thrombolysis/surgery (extensive, limb-
threatening)
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Complications
• PE (~10%)• post-thrombotic syndrome• recurrence DVT (~20%)