A Case of DVT for Discussion

A CASE OF DEEP VEIN A CASE OF DEEP VEIN THROMBOSIS FOR THROMBOSIS FOR

DISCUSSIONDISCUSSION

PROF. P. VIJAYARAGHAVAN’S PROF. P. VIJAYARAGHAVAN’S UNITUNIT

Dr.P.ARUL P.G.Dr.P.ARUL P.G.

►45 years old Mrs. Ammakanu was 45 years old Mrs. Ammakanu was admitted with chief complaints of Left admitted with chief complaints of Left leg swelling 30 days right sided leg swelling 30 days right sided abdominal pain 20 days and abdominal pain 20 days and breathlessness 4 daysbreathlessness 4 days

►History of presenting illness:History of presenting illness:► Patient apparently normal before 30 days. Patient apparently normal before 30 days.

developed left leg swelling and pain. she developed left leg swelling and pain. she was admitted in a private hospital, following was admitted in a private hospital, following treatment the swelling and pain subsided. treatment the swelling and pain subsided. Later she had abdomen pain–dull aching, Later she had abdomen pain–dull aching, more over the right hypochondrium, no more over the right hypochondrium, no aggravating or relieving factors.aggravating or relieving factors.

► Breathlessness present for past 4 days Breathlessness present for past 4 days grade 3 initially and now grade 4.grade 3 initially and now grade 4.

►H/o orthopnea+H/o orthopnea+►H/o vomiting onceH/o vomiting once►No h/o fever or headache.No h/o fever or headache.►No h/o chest pain or palpitation.No h/o chest pain or palpitation.

No h/o coughNo h/o cough

No traumaNo trauma

No h/o altered bladder or bowel habits.No h/o altered bladder or bowel habits.

No h/o altered sensorium.No h/o altered sensorium.

Past history:Past history:

h/o arthritis for which she takes h/o arthritis for which she takes NSAIDSNSAIDS

Not a diabetic or hypertensive or Not a diabetic or hypertensive or asthmatic or epileptic or tuberculous asthmatic or epileptic or tuberculous patientpatient

Treatment history:Treatment history:

Patient was started on warfarin 15 days Patient was started on warfarin 15 days back in a private hospital.back in a private hospital.

Personal historyPersonal history: Takes mixed diet. Not an : Takes mixed diet. Not an alcoholic or tobacco chewer. Regular 3/30 alcoholic or tobacco chewer. Regular 3/30 days menstrual cycle. H/o 3 spontaneous days menstrual cycle. H/o 3 spontaneous abortions +, 2 live children.abortions +, 2 live children.

Family historyFamily history: No similar illness in the family.: No similar illness in the family.

Contact historyContact history: :

No history of contact with patients with No history of contact with patients with tuberculosis.tuberculosis.

►General examinationGeneral examination► Pt conscious, oriented, afebrile,Pt conscious, oriented, afebrile,► dyspneic, tachypneicdyspneic, tachypneic► pallor+, malar rash +pallor+, malar rash +► no icterus/cyanosis/clubbingno icterus/cyanosis/clubbing► no significant lymphadenopathyno significant lymphadenopathy► bilateral pitting pedal edemabilateral pitting pedal edema► generalised swelling of the left lower limbgeneralised swelling of the left lower limb► JVP raisedJVP raised

►Vital signs:Vital signs:►Bp 110/60mm hg Bp 110/60mm hg ►Pulse 76/minPulse 76/min►RR 24/minRR 24/min►Temperature 98.4 FTemperature 98.4 F

EXAMINATION OF CVS:EXAMINATION OF CVS:►S1 S2 heard but muffledS1 S2 heard but muffled►RV-S3 heard RV-S3 heard EXAMINATION OF RS;EXAMINATION OF RS;►NVBS+ . no added sounds.NVBS+ . no added sounds.EXAMINATION OF ABDOMEN:EXAMINATION OF ABDOMEN:►Soft ,bowel sounds heard, liver Soft ,bowel sounds heard, liver

enlarged 7X3.5 cms size, soft, tender .enlarged 7X3.5 cms size, soft, tender .EXAMINATION OF CNS:EXAMINATION OF CNS:►No FND.No FND.

►EXAMINATION OF THE LEFT LL:EXAMINATION OF THE LEFT LL: Limb is swollen through out, tender, dusky Limb is swollen through out, tender, dusky

appearance.appearance. Peripheral pulses felt.Peripheral pulses felt.

INVESTIGATIONSINVESTIGATIONSRBC 3.11millionRBC 3.11millionWBC TC 4000WBC TC 4000 DC p-77%,L-13%,E-10%DC p-77%,L-13%,E-10%Platelet 80,000Platelet 80,000PCV-30PCV-30MCV83.0MCV83.0MCH 25.3MCH 25.3MCHC 30.5 MCHC 30.5 HB-9.4 gm%HB-9.4 gm%ESR 36mm.ESR 36mm.Blood group A+Blood group A+PT control 12-15 sec, test 38PT control 12-15 sec, test 38APTT control 26.test 38APTT control 26.test 38INR 2.2INR 2.2

Blood sugar-141gms/dlBlood sugar-141gms/dlUrea-43Urea-43Creatinine-1.1Creatinine-1.1LIVER FUNCTION TESTLIVER FUNCTION TESTTotal bilirubin 5.4Total bilirubin 5.4Direct 4.3Direct 4.3AST-87.1AST-87.1ALT-242ALT-242GGT-35GGT-35SAP-254SAP-254Total protein 6.8Total protein 6.8Alb 3.1Alb 3.1Globulin 3.7Globulin 3.7

► S.electrolytesS.electrolytes► Sodium 138Sodium 138► Potassium-4.07Potassium-4.07► Chloride-102.5Chloride-102.5► HIV-NEGATIVEHIV-NEGATIVE► HBSag NEGATIVEHBSag NEGATIVE► Anti Hb c NEGATIVEAnti Hb c NEGATIVE► Urine colour yellowUrine colour yellow► appearance clearappearance clear► ph 6.5ph 6.5► sp.gravity 1.025sp.gravity 1.025► Alb-nilAlb-nil► Sugar-nilSugar-nil

► Nitrites –negativeNitrites –negative► Leucocytes 8to 10 hpfLeucocytes 8to 10 hpf► Epithelial cells –occasionalEpithelial cells –occasional► Rbc-2-3/hpfRbc-2-3/hpf► Cxr- cardiomegalyCxr- cardiomegaly► ECG- sinus tachycardia, poor prognosis of r waveECG- sinus tachycardia, poor prognosis of r wave► Urine c&s-no growthUrine c&s-no growth► ANA (homogenous) +ANA (homogenous) +► LUPUS ANTICOAGULANT + LUPUS ANTICOAGULANT + ► ACL ANTIBODY –NEGATIVE.ACL ANTIBODY –NEGATIVE.

► EchoEchoPericardial effusion+Pericardial effusion+Fibrous strands+Fibrous strands+RA collapse+RA collapse+Normal lv systolic functionNormal lv systolic functionMild diastolic dysfunctionMild diastolic dysfunctionMild hypokinesia of IVS AND LV APEXMild hypokinesia of IVS AND LV APEXNo evidence of tamponadeNo evidence of tamponadeNormal chamber dimension,Normal chamber dimension,►Doppler studyDoppler studyLeft popliteal vein thrombosis extending into Left popliteal vein thrombosis extending into

superficial femoral vein.superficial femoral vein.

►Ultra sound abdomenUltra sound abdomen►Minimal free fluid in morrison pouchMinimal free fluid in morrison pouch►HepatomegalyHepatomegaly►Minimal ascitesMinimal ascites►Left pleural effusionLeft pleural effusion►Pericardial effusionPericardial effusion

►Hematologist and rheumatologist Hematologist and rheumatologist opinionopinion

?APLAS?APLAS►Vascular surgeon opinion – DVT Left LLVascular surgeon opinion – DVT Left LL►Elastocrepe bandage, leg elevation, Elastocrepe bandage, leg elevation,

tablet folic acid, in view of jaundice tablet folic acid, in view of jaundice and abnormal PT and INR Heparin and abnormal PT and INR Heparin therapy is deferred.therapy is deferred.

►Cardiologist opinion to start acitrom Cardiologist opinion to start acitrom

DIAGNOSISDIAGNOSIS

►A Case of DVT left lower limb probably A Case of DVT left lower limb probably due to hyper coagulable state (anti due to hyper coagulable state (anti phospholipid antibody syndrome phospholipid antibody syndrome secondary to SLE) with pericardial secondary to SLE) with pericardial effusion, pleural effusion, ascites due effusion, pleural effusion, ascites due to polyserositis. to polyserositis.

DIAGNOSIS – ARA CRITERIADIAGNOSIS – ARA CRITERIA Malar rashMalar rash Discoid rashDiscoid rash photosensitivityphotosensitivity Oral ulcersOral ulcers ArthritisArthritis SerositisSerositis Renal disorderRenal disorder Neurological disorderNeurological disorder Hematological disorderHematological disorder Imm. disorderImm. disorder Antinuclear AbsAntinuclear Abs4 or >likely to be SLE4 or >likely to be SLE

►DEEP VEIN THROMBOSISDEEP VEIN THROMBOSIS

►Commonly affects-leg veins or deep Commonly affects-leg veins or deep veins of pelvis.veins of pelvis.

►Causes and risk factors:Causes and risk factors:►Conditions that cause compression of Conditions that cause compression of

veins, physical trauma, cancer, veins, physical trauma, cancer, infections , certain inflammatory infections , certain inflammatory diseases, specific conditions like diseases, specific conditions like stroke, heart failure and nephrotic stroke, heart failure and nephrotic syndrome.syndrome.

►Surgery, hospitalisation, Surgery, hospitalisation, Immobilisation, smoking,obesity, Immobilisation, smoking,obesity, drugs like estrogens, drugs like estrogens, erythropoietin and diseases like erythropoietin and diseases like thrombophilia.thrombophilia.

►Women have risk during Women have risk during pregnancy and postnatal period,pregnancy and postnatal period,

►Air travelAir travel►May thurner syndromeMay thurner syndrome

►MECHANISM -VIRCHOWS TRIADMECHANISM -VIRCHOWS TRIAD

►Decreased flow rate of blood,Decreased flow rate of blood,►Damage of blood vessel,Damage of blood vessel,► Increased tendency of blood to clotIncreased tendency of blood to clot

►SYMPTOMS AND SIGNSSYMPTOMS AND SIGNS►No symptoms sometimeNo symptoms sometime►Pain,swelling and redness of legPain,swelling and redness of leg►Superficial veins may enlarge.Superficial veins may enlarge.

►COMPLICATIONSCOMPLICATIONS►Pulmonary embolismPulmonary embolism►Post phlebitic syndromePost phlebitic syndrome► INVESTIGATIONSINVESTIGATIONS►Gold standard test-IV venography.Gold standard test-IV venography.►Physical examinationPhysical examination►Homans testHomans test►Pratts signPratts sign

►Wells scoreWells score►Active cancer-1pointActive cancer-1point►Calf swelling>3cms-1ptCalf swelling>3cms-1pt►Collateral veins-1ptCollateral veins-1pt►Pitting edema-1ptPitting edema-1pt►Swelling of entire leg-1ptSwelling of entire leg-1pt

► Localised pain along distribution of deep Localised pain along distribution of deep venous system-1ptvenous system-1pt

► Paralysis,paresis or recent immobilisation of Paralysis,paresis or recent immobilisation of leg-1ptleg-1pt

► Recently bedridden or surgeryor pts Recently bedridden or surgeryor pts requirina GA-1pt requirina GA-1pt

► INTERPRATATION.INTERPRATATION.► 2 OR > PTS-DVT LIKELY2 OR > PTS-DVT LIKELY►<2 DVT UNLIKELY<2 DVT UNLIKELY► BLOOD TESTBLOOD TEST►D-DIMER TESTD-DIMER TEST

►OTHER TESTSOTHER TESTS►CBC, pt APTT, fibrinogen, liver CBC, pt APTT, fibrinogen, liver

enzymes, renal function test and enzymes, renal function test and electrolyteselectrolytes

► Imaging leg veinsImaging leg veins► Impedance plythesmographyImpedance plythesmography►Doppler ultra sonogramDoppler ultra sonogram

TREATMENTTREATMENT

►ANTI COAGULATION MEASURESANTI COAGULATION MEASURES Unfractionated heparinUnfractionated heparin LMW HeparinLMW Heparin WarfarinWarfarin

►Thrombolysis Thrombolysis ►Compression stockingsCompression stockings► IVC filterIVC filter