deep vein thrombosis and pulmonary embolism
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- 1. DVT and PE Evans Omondi Munyaga Byanjo
- 2. CONTENT Definition Epidemiology Aetiology Risk factors Pathophysiology Clinical Presentation Investigations Treatment Complications Prevention
- 3. Defn: Deep vein thrombosis(DVT) Is the formation of blood clots in the deep veins. Most commonly involves calf, femoral or iliac veins. Is less common in the upper limbs but the axillary vein may be involved as a complication of trauma, long venous infusion catheters, neoplasm or radiotherapy.
- 4. Epidemiology Common in older women >40 years Incidence is at 0.2% in ante-natal period and 0.6% in postpartum. The incidence rises to 1- 2% post caesarian section. Left leg>80% Ileofemoral more common than calf vein (72% versus 9%) Unfortunately only 5-10% are symptomatic.
- 5. Aetiology This is based on the Virchows triad: Stasis Endothelial injury Hypercoagulability state Venous stasis-immobility (prolonged bed rest, limb paralysis) low cardiac output(heart failure) varicose veins.
- 6. Venous injury- Trauma, i.v cannulation. Increase coagulability-malignant diseases, drugs(oestrgen,oral contraceptives)dehydration,polycythaemia Inherited coagullation effect- Antithrombin III, protein C, protein S.
- 7. Risk factors Abdominal or pelvic surgery Old age Prolonged surgery and general anaesthesia Obesity Malignancy Prior DVT Increase coagulation diseases-protein C or S
- 8. Oestrogen Oral contraceptive pills Smocking Prolonged bed rest Pregnancy
- 9. Pathophysiology The thrombus occur in the deep veins of the leg. Usually originate around the valves. The calf vein is the usual site. It may also originate in the iliac or femoral vein. There is progressive obstruction following thrombosis in the deep veins.
- 10. Clinical presentation Symptoms: Asymptomatic Pain Swelling Increase in temperature Engorgement of superficial veins Erythema
- 11. Signs: Fever, calf warmth, tenderness, pitting oedema, cyanotic limb. Homans sign (increased resistance/ pain on forced foot dorsiflexion)- may dislodge the thrombus.
- 12. Wells Score Each of following scores a point Active cancer(Rx within last 6mths or palliative) Paralysis, paresis or recent plaster immobilisation Major surgery in last 4wks or recently bedridden > 3days. Local tenderness along distribution of deep venous system Entire leg swollen Calf swelling > 3cm compared to asymptomatic leg measured 10cm below the tibial tuberosity Pitting oedema> in the symptomatic leg Collateral superficial vein
- 13. Alternative diagnosis is more likely than DVT minus 2 pts. Score 3pts, DVT is likely Score 1-2, treat as suspected DVT and perform compression US Score 0 perform D- dimer test.
- 14. Investigations Ascending venograpthy; invasive but more sensitive than duplex Doppler U/S Blood CBC INR Duplex U/S Venography
- 15. Treatment Aim of Rx is to prevent further thrombosis and pulmonary embolisation, Bed rest, elevate the limb, good hydration. Calf vein thrombosis may be treated by compression stockings. LMWH e.g. Enoxaparin preferred to unfractionated heparin because: It has a higher bioavailability. Less risk of bleeding
- 16. Oral anticoagulants: Warfarin- it inhibits synthesis of vitamin k dependent clotting factors (II, VII, IX, X), proteins C and S. LMWH is given first for 3-5 days then Warfarin The duration for Warfarin is still debatable However if the risk is reversible its given for 6wks- 6months Before starting and during treatment, the patients INR is monitored.
- 17. DDx Ruptured Bakers cyst Cellulitis Calf hematoma Lymphoedema
- 18. Complication PE-most feared Venous Gangrene Recurrent DVT Varicose veins Chronic venous insufficiency Post phlebitic syndrome (pain, oedema, ulceration)
- 19. Prevention Avoid the risk factors-obesity,smoking Prevent blood stasis in susceptible patients through ambulation, use of elastic stockings, exercise or elevation of legs Prophylaxis of susceptible patients with low dose Aspirin
- 20. Thank you
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