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Deep Vein Thrombosis

DVT

Deep vein thrombosis is defined as the formation of a thrombus within a deep vein.


Presentation

The following classical signs and symptoms appear in the lower limbs of around 50% of the patients with deep vein thrombi [7] [8].

  • Swelling of the leg
  • Pain or tenderness which may be associated with walking or standing
  • Erythema or discolored skin
  • Dilated superficial veins
  • Low grade fever with increased pulse
  • Calf tenderness

Phlegmasia alba dolens (white leg): This condition is characterized by pain, pitting edema and blanching. There is no associated cyanosis. The condition occurs because of obliteration of the major deep venous channels with relative sparing of collateral veins. As a result, swelling occurs but there is no cyanosis.

Phlegmasia cerulea dolens (Blue leg): The condition occurs when the thrombi involve the deep veins as well as the collateral channels. Thus all the venous outflow is blocked and there is massive fluid sequestration and significant edema. The affected limb in phlegmasia cerulea dolens is extremely painful, edematous and cyanotic and may be associated with arterial insufficiency and compartment syndrome. If untreated venous gangrene ensues which may even require amputation.

Signs

  • Homan’ s Test: Forcible dorsiflexion of foot results in severe pain in the calf region. It is not used commonly now.
  • Moses Test: In this test, tenderness over the calf muscles is elicited on squeezing the muscle from side to side. Ideally, it should not be performed as there is risk of embolization.
Pain
  • One week later he presented to our emergency department with acute sudden increase in the pain and swelling of his left knee, and pain and swelling of his left leg, without any trauma.[ncbi.nlm.nih.gov]
  • They include: Swelling of the leg or along a vein in the leg Pain or tenderness in the leg, which you may feel only when standing or walking Increased warmth in the area of the leg that's swollen or painful Red or discolored skin on the leg Pulmonary[web.archive.org]
  • The patient will present with a swollen, cyanotic, painful leg that may or may not show signs of venous gangrene.[ncbi.nlm.nih.gov]
  • Abstract A previously healthy 21-year-old man presented with back pain, bilateral extremity pain, and right lower extremity weakness, paresthesias, and swelling.[ncbi.nlm.nih.gov]
  • A 32-year-old man with a history of bronchial asthma was referred for low back pain and bilateral femur pain. Vascular sonography revealed bilateral deep vein thrombosis (DVT) from the femoral veins to the popliteal veins.[ncbi.nlm.nih.gov]
Swelling
  • One week later he presented to our emergency department with acute sudden increase in the pain and swelling of his left knee, and pain and swelling of his left leg, without any trauma.[ncbi.nlm.nih.gov]
  • : While rare in infants, new-onset swelling in an extremity may be caused by thrombosis and be the initial symptom of an underlying hypercoagulable state.[ncbi.nlm.nih.gov]
  • It presents as acute non-traumatic swelling and pain of the lower extremity, which can mimic deep vein thrombosis (DVT). The clinical course is usually self-limiting and patients respond well to supportive medical therapy.[ncbi.nlm.nih.gov]
  • Pain or swelling of a lower limb is a common presenting complaint, and a wide differential diagnosis exists (box 1).[doi.org]
  • Local improvement was achieved in the next 4 days with progressive diminishment of local tenderness and swelling. Limb deep vein thrombosis might be induced by snakebite, despite the pro-haemorrhagic general condition induced by the envenomation.[ncbi.nlm.nih.gov]
Leg Swelling
  • A previously healthy 6-month-old male was brought to the emergency department by his family with a chief complaint of left leg swelling. Duplex ultrasonography in the emergency department revealed multiple DVTs in the leg vasculature.[ncbi.nlm.nih.gov]
  • Most DVTs are asymptomatic; however, there may be asymmetrical leg swelling, unilateral leg pain, dilation or distension of superficial veins, and red or discoloured skin.[bestpractice.bmj.com]
  • A 50 years old diabetic Post-Coronary Artery Bypass Grafting gentleman had been suffering for left leg swelling, high grade fever and calf muscle pain for 5 days.[ncbi.nlm.nih.gov]
  • We review a case report of a 66-year-old woman that presented to small community army hospital after a 26-hour bus drive with knee pain and leg swelling.[ncbi.nlm.nih.gov]
  • This condition is characterized by pooling of blood, chronic leg swelling, increased pressure, increased pigmentation or discoloration of the skin, and leg ulcers known as venous stasis ulcers .[my.clevelandclinic.org]
Fever
  • Evidently, patients with dengue fever who have prolonged fever (more than 5 days) and acute kidney injury are at high risk for concurrent bacteremia.[ncbi.nlm.nih.gov]
  • A 32-year-old man was admitted because of fever, hemoptysis and chest pain. The main clinical features include hypereosinophilia, deep vein thrombosis, pulmonary embolism, thrombocytopenia and recurrent bone cysts.[ncbi.nlm.nih.gov]
  • She presented with varicella lesions, fever and a painful firm tumefaction on the right lower leg (RLL). Ultrasound showed a local subcutaneous tissue thickening suggestive of cellulitis and antibiotics were initiated.[ncbi.nlm.nih.gov]
  • A 26-year-old man was admitted to the department of invasive technology with fever and dyspnea. Blood tests showed inflammatory activity, a slight increase of D-dimer and Fibrin Degradation Product.[ncbi.nlm.nih.gov]
  • A 50 years old diabetic Post-Coronary Artery Bypass Grafting gentleman had been suffering for left leg swelling, high grade fever and calf muscle pain for 5 days.[ncbi.nlm.nih.gov]
Congestive Heart Failure
  • heart failure Inflammatory bowel disease ( Crohn's disease or ulcerative colitis ) Some types of cancer, or cancer treatment, may increase levels of certain substances in your blood that cause clots.[everydayhealth.com]
  • Also, there are specific medical conditions that may increase your risk of developing a DVT via these three mechanisms, such as congestive heart failure, severe obesity, chronic respiratory failure, a history of smoking, varicose veins, pregnancy and[vascularcures.org]
  • Your risk of having DVT increases if you have some conditions, including: immobility (bed rest or inability to walk due to illness, injury, or another medical problem) orthopedic surgery fractures of the hip or leg pelvic surgery stroke congestive heart[healthyhorns.utexas.edu]
  • Patients with cancer and other chronic illnesses (including congestive heart failure), as well as those who have experienced a recent heart attack (myocardial infarction), are also at high risk for developing DVT.[medical-dictionary.thefreedictionary.com]
Homans' Sign
  • Of those who responded, 80.5% were taught to use Homans sign to screen for a possible DVT in their entry-level education and 67.9% continued to use Homans sign in clinical practice.[ncbi.nlm.nih.gov]
  • On physical examination, the patient had increased warmth, edema, erythema, and tenderness in the left calf, with positive Homan's sign. A lower-extremity venous Doppler was negative for DVT.[ncbi.nlm.nih.gov]
  • He had absent Arteria Dorsalis Paedis pulse on left foot, Positive Homan sign and Wells score is 7. His left leg was hugely swelled. He had normal leg hair distribution.[ncbi.nlm.nih.gov]
  • Additionally, some patients may have a positive Homan sign on physical examination, whereby there is pain on forceful dorsiflexion while the knee is extended.[radiopaedia.org]
Tachycardia
  • Electrocardiography shows sinus tachycardia. Chest radiography shows small atelectatic changes at the left lung base ( Figure 1 ). Pulmonary embolism is suspected, and a serum Ddimer level is obtained; it is 4,054 ng/mL (reference range 500).[doi.org]
Skin Discoloration
  • Signs or symptoms of postphlebitic syndrome may include: Leg aching and fatigue Aching Swelling Hyperpigmentation or skin discoloration Itching and dry skin of the affected leg The hyperpigmentation or skin discoloration is caused by the breakdown of[umcvc.org]
  • Damage to your veins from the blood clot reduces blood flow in the affected areas, which can cause: Persistent swelling of your legs (edema) Leg pain Skin discoloration Skin sores Prevention Measures to prevent deep vein thrombosis include: Avoid sitting[mayoclinic.com]
Erythema
  • On physical examination, the patient had increased warmth, edema, erythema, and tenderness in the left calf, with positive Homan's sign. A lower-extremity venous Doppler was negative for DVT.[ncbi.nlm.nih.gov]
  • PICC line and upper limb DVT) 6 In the lower limbs, patients often present with unilateral leg pain, swelling, and erythema. On physical examination, the affected leg is often tender and warm, and there may be dilation of superficial veins.[radiopaedia.org]
  • Swelling of the leg Pain or tenderness which may be associated with walking or standing Erythema or discolored skin Dilated superficial veins Low grade fever with increased pulse Calf tenderness Phlegmasia alba dolens (white leg): This condition is characterized[symptoma.com]
  • […] doctor immediatrly if you have any of the following signs or symptoms: Edema (swelling) of the leg or along a vein in the leg Pain and tenderness in the leg, which you may only feel when standing or walking Warmth in the swollen area of the leg Fever Erythema[ksi.uconn.edu]
Warm Skin
  • Symptoms of DVT Call your doctor's office right away if you have any of these symptoms, especially if they appear suddenly: Swelling in one or both legs Pain or tenderness in one or both legs, even if it's just when you stand or walk Warm skin on your[webmd.com]
  • You may notice redness or warm skin at the affected part.[diabetes.co.uk]
  • If symptoms do occur they can include: pain, swelling and tenderness in one of your legs (usually your calf) a heavy ache in the affected area warm skin in the area of the clot red skin, particularly at the back of your leg below the knee DVT usually[nhs.uk]
Leg Pain
  • We report a case of a patient presenting with acute leg pain resembling that of a deep vein thrombosis, and a beginning leg compartment syndrome following a suspected ruptured Baker's cyst.[ncbi.nlm.nih.gov]
  • A 59-year-old white man with history of leg pain, smoking, weight loss, benign prostatic hyperplasia, lipoma and panic attack presented with shortness of breath and chest pain for 2 days precipitated by not feeling well for months.[ncbi.nlm.nih.gov]
  • A healthy 21-year-old man presented with a 2-day history of worsening left leg pain with swelling and bluish discolouration.[ncbi.nlm.nih.gov]
  • Deep vein thrombosis can cause leg pain or swelling, but also can occur with no symptoms. Deep vein thrombosis can develop if you have certain medical conditions that affect how your blood clots.[mayoclinic.com]
Calf Pain
  • Shutterstock So now you’ve got phantom calf pain and you’re convinced you can’t breathe, right? Believe us, we get it.[bicycling.com]
  • Common causes of calf pain that mimic acute DVT include venous insufficiency and postphlebitic syndrome; cellulitis that causes painful erythema of the calf; ruptured popliteal (Baker) cyst (pseudo-DVT), which causes calf swelling, pain, and sometimes[web.archive.org]
Panic Attacks
  • A 59-year-old white man with history of leg pain, smoking, weight loss, benign prostatic hyperplasia, lipoma and panic attack presented with shortness of breath and chest pain for 2 days precipitated by not feeling well for months.[ncbi.nlm.nih.gov]

Workup

The investigations that are necessary to diagnose deep vein thrombosis include:

  • Duplex ultrasound: Duplex ultrasound is the test of choice to diagnose deep vein thrombosis as it is non-invasive, hazard-free and reliable.
  • Contrast venography: Radio-opaque dye is injected into dorsal venous arch and an x-ray radiograph is taken. A clot if present appears as a filling defect.
  • Blood tests: People with severe deep vein thrombosis have an elevated level of a clot-dissolving substance called D-dimer. Many inherited and acquired causes of hypercoagulability such as anti-thrombin III, protein C or protein S deficiency can also be detected by blood test.
  • CT scan or MRI scans: These investigations are helpful as they can provide visual images of veins and may show a clot.

Treatment

The treatment options for deep vein thrombosis include the following.

  • Elevation of limb: This is essential to regulate unidirectional flow of blood.
  • Compression stockings: These help prevent the swelling associated with deep vein thrombosis. These are worn on the legs from feet to above the level of knees.
  • Filters: A filter may be inserted into a large vein (such as the vena cava) that prevents clots that break loose from lodging into lungs [9].
  • Blood thinners: The anticoagulants used to treat deep vein thrombosis include heparin and warfarin. Intravenous heparin is given according to weight of patient. Generally 10,000 units intravenous bolus with continuous infusion of 30,000 to 45,000 units per day is given. Warfarin is started 2-3 days before withdrawal of heparin because of its slow onset of action.
  • Venous thrombectomy: Thrombus can be removed by opening the femoral vein via incision in the groin.
  • Thrombolysis: This is a modern technique. Catheter is passed in the vein and streptokinase is infused locally to cause thrombolysis [10].

Prognosis

Many individuals who have a first episode of deep vein thrombosis will have a recurrent event. The risk of recurrence may be reduced by the use of compression stockings. Untreated cases of deep vein thrombosis can lead to pulmonary embolism which is one significant causes of death in these patients [6].

Etiology

The various factors responsible for deep vein thrombosis include the following:

  • Trauma: This leads to the injury to vessel wall. A broken hip or leg and subsequent surgeries are the common causes for the development of venous thrombi [1].
  • Hormones: Oral contraceptive pills and the current use of hormone therapy especially in postmenopausal women can contribute to this condition.
  • Road traffic accidents: Accidents causing trauma can also reduce blood flow to any part of the body leading to thrombosis.
  • Operations: Surgical procedures such as cholecystectomy and splenectomy can be a common cause of deep vein thrombosis.
  • Malignancy: People with cancer or a malignant mass have an increased risk for the development of deep vein thrombosis.
  • Blood disorders: Conditions such as thrombophilia that cause the blood to clot more easily than normal can increase the risk [2] [3].
  • Obesity: Obesity, especially in older people over 60 years of age, is closely linked with the development of deep vein thrombosis.
  • Stroke: Conditions like stroke and heart failure increase the risk of deep vein thrombosis.
  • Immobilization: Any illness or injury that causes immobility predisposes the person to the formation of deep vein thrombi [4]. Long travel is often a risk factor [5].
  • Male gender: Deep vein thrombosis is more common in men as compared to women.

Epidemiology

Deep vein thrombosis is more common in men than in women. The incidence is four times higher in the elderly over the age of 60 years.

In the United States, it is estimated that about 1 in 1,000 people have a deep vein thrombosis each year. On average, one in every 20 people develops deep vein thrombosis at least once in the course of his or her lifetime.

Sex distribution
Age distribution

Pathophysiology

The pathophysiology of thrombus formation in deep vein thrombosis is explained by Virchow’s triad.

  • Endothelial injury: Endothelial damage in the blood vessel that may be intrinsic or due to external trauma leads to rupture of the vessel wall. This reduces the blood flow to a particular part, which activates certain biochemical pathways, leading to thrombus formation. The factors causing endothelial injury include hypertension, endotoxin, trauma, smoking and antiphospholipid syndrome.
  • Venous stasis: Certain conditions like cardiac arrhythmias, aneurysms and prolonged period of rest after surgery lead to stasis or turbulence of blood flow. Lack of motion can cause sluggish blood flow causing thrombus formation.
  • Blood hypercoagulability: Blood may become thick and clot easily in certain inherited conditions like antithrombin III deficiency and protein C or S deficiency. Hormone therapy and birth control pills also can increase the risk of clot formation.

Prevention

Deep vein thrombosis can be prevented by ensuring of a healthy life style, proper diet and regular exercise. Long periods of immobility must be avoided after major surgical procedures or on long travels.

People who are overweight must reduce their weight to prevent the risk of deep vein thrombosis. Regular checking of blood pressure with plenty of fluids intake and avoid smoking may also help prevent the risk of deep vein thrombosis.

Summary

Deep vein thrombosis is a condition in which there is formation of blood clots in the deep veins. These blood clots are known as thrombi and they can form in veins anywhere in the body; however, the large veins in legs and thighs are most frequently involved.

The condition is characterized by swelling, pain and tenderness, often in the legs. Risk factors for the formation of thrombi include immobility, hormone therapy and pregnancy. Deep vein thrombosis are most common in the elderly over 60 years of age; however, no age is immune.

A thrombus in a deep vein can break off and travel to lungs through bloodstream, leading to pulmonary embolism.

Patient Information

Deep vein thrombosis is a blood clot that usually forms in the deep veins of the lower leg and thigh. The patients usually develop swelling and pain of the leg and changes in the color of the overlying skin. Sitting for long periods when travelling can increase the risk of deep vein thrombosis. With proper medications and regular exercise, the disease has a good prognosis.

References

Article

  1. Stamatakis JD, Kakkar VV, Sagar S, Lawrence D, Nairn D, Bentley PG. Femoral vein thrombosis and total hip replacement. British medical journal. Jul 23 1977;2(6081):223-225.
  2. Dahlback B. Inherited thrombophilia: resistance to activated protein C as a pathogenic factor of venous thromboembolism. Blood. Feb 1 1995;85(3):607-614.
  3. Jensen R, Ens GE. Resistance to activated protein C: a major cause of inherited thrombophilia. Clinical laboratory science : journal of the American Society for Medical Technology. Jul-Aug 1997;10(4):219-222.
  4. Slipman CW, Lipetz JS, Jackson HB, Vresilovic EJ. Deep venous thrombosis and pulmonary embolism as a complication of bed rest for low back pain. Archives of physical medicine and rehabilitation. Jan 2000;81(1):127-129.
  5. Arfvidsson B. Risk factors for venous thromboembolism following prolonged air travel: a prospective study. Cardiovascular surgery. Apr 2001;9(2):158-159.
  6. Tapson VF. Acute pulmonary embolism. The New England journal of medicine. Mar 6 2008;358(10):1037-1052.
  7. McLachlin J, Richards T, Paterson JC. An evaluation of clinical signs in the diagnosis of venous thrombosis. Archives of surgery. Nov 1962;85:738-744.
  8. Haeger K. Problems of acute deep venous thrombosis. I. The interpretation of signs and symptoms. Angiology. Apr 1969;20(4):219-223.
  9. Jaff MR, McMurtry MS, Archer SL, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. Apr 26 2011;123(16):1788-1830.
  10. Todd JL, Tapson VF. Thrombolytic therapy for acute pulmonary embolism: a critical appraisal. Chest. May 2009;135(5):1321-1329.

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Last updated: 2018-06-22 03:48