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Deep Vein Thrombosis

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Deep Vein Thrombosis

Causes

Deep vein thrombosis is extremely common. It is a thrombus that occludes the deep veins of the lower limbs, or less commonly the pelvic veins. It can either arise spontaneously or as a result of predisposing risk factors. This clot commonly travels to the lungs causing a pulmonary embolism.

Major risk factors include:

  • Previous episode of DVT (commonest)
  • Surgery
  • Immobility/Prolonged travel
  • Malignancy
  • Thrombophilia

Minor risk factors include:

  • Pregnancy
  • Hormonal therapies: HRT, Contraceptive pills
  • Tamoxifen

Signs/ Symptoms

Not all DVT is symptomatic !! In fact, 65% of below-knee DVT is asymptomatic - therefore MUST assess for risk factors using a 'Wells' Score.

Classical features are:

  • A warm, tender, swollen calf (or thigh) : this is usually unilateral. (If bilateral, think pelvic veins)
  • Mild fever
  • Distended superficial veins
  • Pitting Oedema
  • Also look for signs/symptoms of PE!!!!

Differentials

- Main differential to rule out is CELLULITIS! (presents very similarly, both can co-exist or one can cause the other)

-Ruptured baker's cyst

-Trauma

-Arthritis

Investigations

  • To be guided by Wells Score (testing for probability of DVT) but include:

- D Dimer - generally do if low-risk as this is sensitive but not specific for DVT.

-Duplex USS - is definitive. generally do if medium/high risk

-Contrast venogram

  • Consider looking for underlying cause if no obvious risk factors/ if recurrent DVT/ if family history of DVT:

-In young patient: do thrombophilia tests

-In older patient: Look for underlying malignancy

Management

1) ANTICOAGULATION - with Low Molecular Weight Heparin e.g. enoxaparin/fondaparinux) & Warfarin. Stop heparin when INR 2-3 . Duration of therapy is dependent on cause - if underlying cause, likely to need lifelong therapy. If idiopathic, likely 6 months.

2) IVC Filters - if refractory to anticoagulants, or to prevent PE

3) Compression Stockings: prevent long-term complications f DVT

Complications

1) PE

2) Recurrence (recurrence rate very high!!)

3) Post-thrombotic syndrome