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| | __NOTOC__ |
| | {| class="infobox" style="float:right;" |
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| | | [[File:Siren.gif|30px|link=Deep vein thrombosis resident survival guide]]|| <br> || <br> |
| | | [[Deep vein thrombosis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
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| {{Deep vein thrombosis}} | | {{Deep vein thrombosis}} |
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| '''For patient information page, click [[{{PAGENAME}} (patient information)|here]] | | '''For patient information page, click [[{{PAGENAME}} (patient information)|here]]''' |
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| '''For main page on Venous Thrombosis, click [[Venous thrombosis|here]] | | '''For economy class syndrome, click [[economy class syndrome|here]]''' |
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| {{Infobox_Disease |
| | '''For main page on venous thrombosis, click [[Venous thrombosis|here]]''' |
| Name = {{PAGENAME}} |
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| Image = |
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| Caption = |
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| DiseasesDB = 3498 |
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| ICD10 = {{ICD10|I|80|2|i|80}} |
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| ICD9 = {{ICD9|453.40}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = |
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| MeshID = D020246 |
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| }}
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| {{SI}}
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| {{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}} [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]
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| ==[[Deep vein thrombosis overview|Overview]]==
| | '''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; {{AE}} {{CZ}}; [[User:Kashish Goel|Kashish Goel, M.D.]]; [[User:Justine Cadet|Justine Cadet]]; {{Rim}} |
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| ==[[Deep vein thrombosis pathophysiology|Pathophysiology]]==
| | {{SK}} DVT |
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| ==[[Deep vein thrombosis epidemiology and demographics|Epidemiology and Demographics]]== | | ==[[Deep vein thrombosis overview|Overview]]== |
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| ==[[Deep vein thrombosis risk factors|Risk factors]]== | | ==[[Deep vein thrombosis classification scheme|Classification]]== |
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| ==[[Deep vein thrombosis diagnosis|Diagnosis]]== | | ==[[Deep vein thrombosis pathophysiology|Pathophysiology]]== |
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| ==[[Deep vein thrombosis treatment|Treatment]]== | | ==[[Deep vein thrombosis causes|Causes]]== |
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| [[Deep vein thrombosis medical therapy|Medical Therapy]] | [[Deep vein thrombosis surgery|Surgery]] | [[Deep vein thrombosis primary prevention|Primary Prevention]] | [[Deep vein thrombosis secondary prevention|Secondary Prevention]] | | ==[[Deep vein thrombosis differential diagnosis|Differentiating Deep Vein Thrombosis from other Diseases]]== |
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| ===Signs and symptoms=== | | ==[[Deep vein thrombosis epidemiology and demographics|Epidemiology and Demographics]]== |
| There may be no symptoms referrable to the location of the DVT, but the classical symptoms of DVT include [[Pain and nociception|pain]], [[swelling]] and redness of the [[leg]] and dilation of the surface veins. In up to 25% of all hospitalized patients, there may be ''some'' form of DVT, which often remains clinically inapparent (unless [[pulmonary embolism]] develops).
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| There are several techniques during physical examination to increase the detection of DVT, such as measuring the circumference of the affected and the contralateral limb at a fixed point (to objectivate [[edema]]), and palpating the [[vein|venous]] tract, which is often tender. Physical examination is unreliable for excluding the diagnosis of deep vein thrombosis.
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| In phlegmasia alba dolens, the leg is pale and cool with a diminished arterial pulse due to spasm. It usually results from acute occlusion of the iliac and femoral veins due to DVT.
| | ==[[Deep vein thrombosis risk factors|Risk Factors]]== |
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| In phlegmasia cerulea dolens, there is an acute and nearly total venous occlusion of the entire extremity outflow, including the iliac and femoral veins. The leg is usually painful, cyanosed and oedematous. Venous gangrene may supervene.
| | ==[[Deep vein thrombosis triggers|Triggers]]== |
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| It is vital that the possibility of pulmonary embolism be included in the history, as this may warrant further investigation (''see'' [[pulmonary embolism]]).
| | ==[[Deep vein thrombosis screening|Screening]]== |
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| A careful history has to be taken considering ''risk factors'' (see below), including the use of estrogen-containing methods of [[hormonal contraception]], recent long-haul flying, and a history of [[miscarriage]] (which is a feature of several disorders that can also cause thrombosis). A family history can reveal a [[genetic disorder|hereditary]] factor in the development of DVT.
| | ==[[Deep vein thrombosis natural history|Natural History, Complications and Prognosis]]== |
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| <gallery>
| | ==Diagnosis== |
| Image:Extremities dvt.jpg|Deep venous thrombosis
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| Image:Extremities dvt2.jpg|Deep venous thrombosis
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| Image:Extremities dvt3.jpg|Deep venous thrombosis
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| </gallery>
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| ===Physical examination===
| | [[Deep vein thrombosis diagnostic approach|Diagnostic Approach]] | [[Deep vein thrombosis assessment of clinical probability and risk scores|Assessment of Clinical Probability and Risk Scores]] | [[Deep vein thrombosis assessment of probability of subsequent VTE and risk scores|Assessment of Probability of Subsequent VTE and Risk Scores]] | [[Deep vein thrombosis history and symptoms|History and Symptoms]] | [[Deep vein thrombosis physical examination|Physical Examination]] | [[Deep vein thrombosis laboratory tests|Laboratory Findings]] | [[Deep vein thrombosis ultrasound| Ultrasound]] | [[Deep vein thrombosis venography| Venography]] | [[Deep vein thrombosis CT|CT]] | [[Deep vein thrombosis MRI|MRI]] | [[Deep vein thrombosis other imaging findings|Other Imaging Findings]] |
| # [[Homan's test]]: Dorsiflexion of foot elicits pain in posterior calf
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| # Pratt's sign: Squeezing of posterior calf elicits pain
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| However, these [[medical sign]]s do not perform well and are not included in [[clinical prediction rule]]s that combine best findings in order to diagnose DVT.<ref name="pmid16403932">{{cite journal |author=Wells PS, Owen C, Doucette S, Fergusson D, Tran H |title=Does this patient have deep vein thrombosis? |journal=JAMA |volume=295 |issue=2 |pages=199-207 |year=2006 |pmid=16403932 |doi=10.1001/jama.295.2.199}}</ref>
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| ===Probability scoring=== | | ==Treatment== |
| In 2006, Scarvelis and Wells overviewed a set of [[clinical prediction rule]]s for DVT,<ref>{{cite journal | author = Scarvelis D, Wells P | title = Diagnosis and treatment of deep-vein thrombosis. | journal = CMAJ | volume = 175 | issue = 9 | pages = 1087-92 | year = 2006 | id = PMID 17060659. [http://www.cmaj.ca/cgi/content/full/175/9/1087 Free Full Text] }}</ref> on the heels of a widely adopted set of clinical criteria for pulmonary embolism.<ref>Neff MJ. ACEP releases clinical policy on evaluation and management of pulmonary embolism. ''American Family Physician''. 2003; '''68'''(4):759-?. Available at: [http://www.aafp.org/afp/20030815/practice.html http://www.aafp.org/afp/20030815/practice.html]. Accessed on: December 8, 2006.</ref><ref>{{cite journal | author = Wells P, Anderson D, Rodger M, Ginsberg J, Kearon C, Gent M, Turpie A, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J | title = Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. | journal = Thromb Haemost | volume = 83 | issue = 3 | pages = 416-20 | year = 2000 | id = PMID 10744147}}</ref>
| | [[Deep vein thrombosis treatment approach|Treatment Approach]] | [[Deep vein thrombosis medical therapy|Medical Therapy]] | [[Deep vein thrombosis compression stockings|Compression stockings]] | [[Deep vein thrombosis IVC filter|IVC filter]] | [[Deep vein thrombosis invasive therapy|Invasive Therapy]] | [[Deep vein thrombosis surgery|Surgery]] | [[Deep vein thrombosis prevention|Prevention]] | [[Deep vein thrombosis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Deep vein thrombosis future or investigational therapies|Future or Investigational Therapies]] |
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| ===Wells score or criteria=== | | == Special Scenarios == |
| (Possible score -2 to 9)
| | [[Deep vein thrombosis special scenario upper extremity|Upper Extremity DVT]] | [[Deep vein thrombosis special scenario recurrence|Recurrence]] | [[Deep vein thrombosis special scenario pregnancy|Pregnancy]] |
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| :1) Active cancer (treatment within last 6 months or palliative) -- 1 point
| | ==Trials== |
| :2) Calf swelling >3 cm compared to other calf (measured 10 cm below tibial tuberosity) -- 1 point
| | [[Deep vein thrombosis landmark trials in treatment|Landmark Trials]] |
| :3) Collateral superficial veins (non-varicose) -- 1 point
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| :4) Pitting edema (confined to symptomatic leg) -- 1 point
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| :5) Swelling of entire leg - 1 point
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| :6) Localized pain along distribution of deep venous system -- 1 point
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| :7) Paralysis, paresis, or recent cast immobilization of lower extremities -- 1 point
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| :8) Recently bedridden > 3 days, or major surgery requiring regional or general anesthetic in past 12 weeks -- 1 point
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| :9) Previously documented DVT -- 1 point
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| :10) Alternative diagnosis at least as likely -- Subtract 2 points
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| ===Interpretation=== | | ==Case Studies== |
| : Score of 2 or higher - deep vein thrombosis is likely. Consider imaging the leg veins.
| | [[Deep vein thrombosis case study one|Case #1]] |
| : Score of less than 2 - deep vein thrombosis is unlikely. Consider blood test such as [[d-dimer]] test to further rule out deep vein thrombosis.
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| ===Blood tests===
| | [[Category:Medicine]] |
| ====D-dimer====
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| {{main|d-dimer}}
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| In a low-probability situation, current practice is to commence investigations by testing for [[D-dimer]] levels. This cross-linked [[fibrin degradation product]] is an indication that [[thrombosis]] is occurring, and that the [[blood clot]] is being dissolved by [[plasmin]]. A low D-dimer level should prompt other possible diagnoses (such as a ruptured [[Baker's cyst]], if the patient is at sufficiently low clinical probability of DVT.<ref name="pmid14507948">{{cite journal |author=Wells PS, Anderson DR, Rodger M, ''et al'' |title=Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis |journal=N. Engl. J. Med. |volume=349 |issue=13 |pages=1227-35 |year=2003 |pmid=14507948 |doi=10.1056/NEJMoa023153}}</ref><ref name="pmid12755550">{{cite journal |author=Bates SM, Kearon C, Crowther M, ''et al'' |title=A diagnostic strategy involving a quantitative latex D-dimer assay reliably excludes deep venous thrombosis |journal=Ann. Intern. Med. |volume=138 |issue=10 |pages=787-94 |year=2003 |pmid=12755550 |doi=}}</ref>
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| ====Other blood tests====
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| Other blood tests usually performed at this point are:
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| * [[complete blood count]]
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| * Primary [[coagulation]] studies: [[prothrombin time|PT]], [[APTT]], [[Fibrinogen]]
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| * [[liver enzyme]]s
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| * [[renal function]] and [[electrolyte]]s
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| ===Imaging the leg veins===
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| [[Impedance plethysmography]], Doppler ultrasonography, compression [[medical ultrasonography|ultrasound]] scanning of the leg veins, combined with duplex measurements (to determine blood flow), can reveal a [[blood clot]] and its extent (i.e. whether it is below or above the [[knee]]).
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| ====Examples====
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| [http://www.radswiki.net Images courtesy of RadsWiki]
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| *'''Example #1: CT images: DVT at left leg'''
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| <br>
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| <div align="left">
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| <gallery heights="125" widths="125">
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| Image:DVT-001.jpg
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| Image:DVT-002.jpg
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| </gallery>
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| </div>
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| *'''Example #2: 2D TOF GRE MRV images: Bilateral deep vein thromboses'''
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| [http://www.radswiki.net Images courtesy of RadsWiki]
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| <div align="left">
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| <gallery heights="125" widths="125">
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| Image:Deep-vein-thrombosis-on-MRV-001.jpg
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| Image:Deep-vein-thrombosis-on-MRV-002.jpg
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| Image:Deep-vein-thrombosis-on-MRV-003.jpg
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| </gallery>
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| </div>
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| ==Prognosis==
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| [[Post-thrombotic syndrome|Post-phlebitic syndrome]] occurs in 10% of patients with deep vein thrombosis (DVT). It presents with leg oedema, pain, nocturnal cramping, venous claudication, skin pigmentation, dermatitis and [[venous ulcer|ulceration]] (usually on the medial aspect of the lower leg).
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| ===Ongoing Health Care Needs===
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| Medicines that thin your blood and prevent blood clots are used to treat DVT. These medicines can thin your blood too much and cause bleeding (sometimes inside the body). This side effect can be life threatening.
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| Bleeding may occur in the digestive system or the brain. Signs and symptoms of bleeding in the digestive system include:
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| * Bright red vomit or vomit that looks like coffee grounds
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| * Bright red blood in your stools or black, tarry stools
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| * Pain in your abdomen
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| Signs and symptoms of bleeding in the brain include:
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| * Severe pain in your head
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| * Sudden changes in your vision
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| * Sudden loss of movement in your arms or legs
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| * Memory loss or confusion
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| If you have any of these signs or symptoms, get treatment right away.
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| ==References==
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| {{Reflist|2}}
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| ==See also==
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| *[[Venogram (medical)]]
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| {{Circulatory system pathology}}
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| {{SIB}}
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| [[ar:تجلط الوريد العميق]]
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| [[it:Trombosi venosa profonda]]
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| [[nl:Diep-veneuze trombose]]
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| [[pt:Trombose venosa profunda]]
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| [[Category:Disease state]]
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
| [[Category:Hematology]] | | [[Category:Hematology]] |
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| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| [[Category:Vascular surgery]] | | [[Category:Vascular surgery]] |
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