Exam Cram 

• DVT: deep vein thrombosis- blood clot in veins in calf, part of Venous Thrombotic Disease with PEs

• Presentation: unilateral calf- sudden onset pain & swelling

• Diagnosis: ultrasound doppler of lower limb veins

• Management: anticoagulation

Outline 

Assessment

History

• Acute onset

• Unilateral calf swelling and pain

• Previous venous thromboembolism

Examination

• Unilateral swollen, tender and erythema

Investigations

• Raised d-dimer

• Confirmed on imaging: ultrasound, CT or MR angiography

Diagnosis 

Diagnostic criteria: Imaging signs- usually ultrasound

Differentials: Baker's cyst rupture, cellulitis, heart failure, musculoskeletal sprain

Classification: severity

• Aetiology:

  • Provoked

  • Unprovoked

    • Idiopathic/ primary

    • Secondary causes

• Location: has to be a deep vein not a superficial vein

Management

Acute

• Anticoagulation: usually apixaban- 

  • 10mg BD for two weeks 

  • 5mg BD for at least 3 months

  • Review by haematology / GP / Gen Med

• Consider ultrasound other leg- to rule out baseline DVT for later comparison

• Analgesia: paracetamol, ibuprofen

• Consider bandage stockings

Long term

OP FU Haematology/ Gen Med / GP

• Duration of anticoagulation

• Requirement to investigate for secondary causes

Med Reg Notes

Management II

If repeat DVT whilst on DOAC- escalate to warfarin

If weight > 100kg, DOACs may be less effective than warfarin. Rivaroxaban & apixaban upper limit would be 120kg. 

Complications

• Pulmonary Embolus 

• Post thrombotic syndrome

• Further DVTs

Secondary Causes

• Thrombophilia

• Malignancy

• Inflammatory condition: Antiphospholipid Syndrome (APS) 

Thrombophilia screen (6)

1. Protein C deficiency

2. Protein S deficiency

3. Antithrombin deficiency (previously thrombin III)

4. Factor V Leiden (controversial)

5. Homocystinuria

6. Prothrombin gene mutation

7. Antiphospholipid syndrome (APS): anti B2 glycoprotein-1, anti-cardiolipin

Superficial Vein Thrombosis

Superficial vein thrombosis is a thrombus in a vein superficially, commonly a varicose vein.

On examination this is a lump within a varicose vein but requires diagnosis on ultrasound (to rule out DVT)

Limited evidence here. 

Minimal risk of PE but enoxaparin may improve recovery and appearance of clot so can be offered if no contraindications

Pregnancy

Increases risk of DVT, highest risk is 6 weeks after delivery (5x)

Management: 

• Enoxaparin till 6 weeks post partum

• Warfarin & DOACs contraindicated

Resources and References

Written 2024.