Diagnosis, investigation, and management of deep vein thrombosis

doi:10.1136/bmj.326.7400.1180

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Clive Tovey, consultant in emergency medicine (clive.tovey@nglamtr.wales.nhs.uk)1,
Suzanne Wyatt, consultant in emergency medicine2

¹ Prince Charles Hospital, Merthyr Tydfil, Mid Glamorgan CF47 9DT
² Princess of Wales Hospital, Bridgend, Mid Glamorgan CF31 1RQ

Correspondence to: C Tovey

Deep vein thrombosis is an important cause of morbidity and mortality worldwide, and its clinical diagnosis is unreliable. This article explains current screening and diagnostic methods as well as treatment

Introduction

Venous thromboembolic disease has an estimated annual incidence in developed countries of one in 1000 people.1 The disorder commonly manifests as deep vein thrombosis of the leg, but deep venous thrombosis may also occur in other veins (cerebral sinus, arms, retina, and mesentery).

The sequelae of deep vein thrombosis vary from complete resolution of the clot without any ill effects through to death due to pulmonary embolism. Morbidity due to deep vein thrombosis includes post-thrombotic syndrome, encompassing chronic venous hypertension causing limb pain, swelling, hyperpigmentation, dermatitis, ulcers, venous gangrene, and lipodermatosclerosis.

Pain or swelling of a lower limb is a common presenting complaint, and a wide differential diagnosis exists (box 1). No single investigation for the diagnosis of deep vein thrombosis has ideal properties (100% sensitivity and specificity, low cost, no risk), and often several tests are performed, either sequentially or in combination.

Box 1: Possible causes of pain or swelling of the lower limb

Venous

Deep vein thrombosis
Superficial thrombophlebitis
Post-thrombotic syndrome
Chronic venous insufficiency
Venous obstruction

Other

Cellulitis
Baker's cyst
Torn gastrocnemius muscle
Fracture
Haematoma
Acute arterial ischaemia
Lymphoedema
Hypoproteinaemia (for example, cirrhosis, nephrotic syndrome)

Summary points

Deep vein thrombosis is an important cause of morbidity and mortality

Clinical diagnosis is unreliable

Screening investigations include D-dimer tests and plethysmographic techniques

Definitive diagnosis is usually by venography or ultrasonography

Initial treatment is with heparin—unfractionated or low molecular weight—followed by oral anticoagulation

Outpatient treatment of deep vein thrombosis is safe

With the introduction of low molecular weight heparins it is now possible to treat deep vein thrombosis as an outpatient condition. This review describes the investigations used in the diagnosis of deep vein thrombosis of the lower limb and the further management of the condition. …