Intended for healthcare professionals

Rapid response to:

Practice Clinical Update

Deep vein thrombosis

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k351 (Published 22 February 2018) Cite this as: BMJ 2018;360:k351
cropped thumbnail of infographic

Investigating DVT

An approach to symptoms suggestive of lower deep vein thrombosis (DVT)

Rapid Response:

The opportunity to diagnose a deep vein thrombosis

Very motivated by the interesting and didactic article published in BMJ last day 22 February 2018 by MJ Stubbs, Maria Mouyis and Mari Thomas entitled deep vein thrombosis (DVT), we wish to highlight the opportunity that every non-specialist doctor has, to diagnose this condition in a patient to be able to impose the treatment as soon as possible and avoid the patient's torpid evolution, which can reach massive pulmonary embolism and sudden death.

Deep vein thrombosis is a frequent and potentially serious disease. It is an extremely common medical problem that occurs isolated or associated with other diseases or procedures.

It is based very well on the BMJ article what needs to be known and especially the detection of transient, persistent risk factors and when considering an unprovoked DVT.

For many years the Virchow triad has explained the pathogenesis of DVT (venous stasis, endothelial damage and increased coagulability). The venous thrombus is formed mainly at the level of the venous valves, where the blood tends to stagnate.

DVT can occur at any age, although it is common in people over 50 years, it can occur without symptoms in 25% of people, but in many cases the affected limb will become painful, swollen, red, hot and superficial veins it can be distended full of blood that circulates badly.

The biggest complication of a DVT is that it could dislodge the clot and travel to the lungs, causing a pulmonary embolism. Therefore, DVT is a medical emergency, which if present in the lower extremity there is a 3% chance that it is lethal to the individual. A late complication of DVT is postphlebitic syndrome, which can manifest as edema, pain or discomfort and skin disorders.

It is known that the main symptoms and signs of DVT are asymptomatic and among them are the following clinical findings and we highlight in the clinical signs the physical examination:

• Mahler's sign: pain that causes functional impotence, can affect the entire limb, tachycardia without fever is of great value.
• Sign of Homans: presence of pain in the upper part of the calf when performing the forced dorsiflexion of the foot with the knee flexed at a 30º angle.
• Neuhoff sign: filling, infiltration or sensitivity at the level of the twins on palpation.
• Olow sign: pain at compression of the muscle mass against the bony plane.
• Rosenthal's sign: pain to the passive extension of the foot at 45º or less.

While none of the symptoms or signs of DVT is diagnosed in isolation, the BMJ article recommends that in 1997 Wells5 established a predictive diagnostic model that takes into account the symptoms, signs and risk factors. This model allows categorizing patients with a high or low likelihood of DVT and is widely used by physicians.

In patients with symptoms suggestive of DVT, the clinical probability should be determined initially according to the Wells model. For this, the preparation of a precise and detailed clinical history is important. After the clinical prediction, determination of D-dimer should be made.

Deep vein thrombosis presents with a symptomatic procession that can generate doubts in the physician. The detailed anamnesis and the correct physical examination provide data of undoubted value for the diagnosis. The Wells Test can help to clarify the diagnostic uncertainty and narrow the spectrum of entities to be discarded.

The opportunity for a rapid and effective diagnosis can lead to a good evolution in a patient with DVT.
Rereferences
1.Kahn S. The clinical diagnosis of Deep Venous Thrombosis Integrating incidence, risk factors, and symptoms and signs. Arch Intern Med. 1998;158:2315-23.
2. López JA, Kearon C, Lee AY. Deep Venous Thrombosis Hematol. 2004;53:439-55.
3. Otero Candelera R, Gonzáles Vergara D. Enfermedad tromboembólica venosa. Diagnóstico y tratamiento. 2010 [citado15 Jul 2012]. Disponible en: http://www.neumosur.net/files/EB04-40%20ETEV.pdf
4. Othieno R, Abu Affan M, Okpo E. Tratamiento domiciliario versus hospitalario para la trombosis venosa profunda (Revisión Cochrane traducida). UK: John Wiley & Sons, Ltd. La Biblioteca Cochrane Plus. Traducida de The Cochrane Library, 2008 Issue 3. Chichester. 2008;3(4).
5. Páramo JA. Diagnóstico y tratamiento de la trombosis venosa profunda. Rev Med Univ Navarra. 2007;51(1):13-7.
6. Samama M, Dahl O, Quinlan D, Mismetti P. Quantification of risk factors for venous thromboembolism a preliminary study for the development of a risk assessment tool. Haematologica. 2003;88:1410-21.
7. Caprini J, Arcelus J, Ryna J. Effective Risk Stratification of surgical and not surgical patients for venous Thromboembolic disease. Semin Hematol. 2009;38(suppl.5):12-9.
8. Cushman M;Folsom AR, Wang L, Aleksic N, Rosamond WD, Tracy RD et al. Fibrin fragment D-Dimer and the risk of future venous thrombosis. Blood. 2010;101;1243-8.
9. Frederick A, Anderson J, Frederick AS. Risk factors for venous thromboembolism. Circulation. 2003;107:9-16.
10. Baron JA, Gridley G, Weiderpass E, Nyren O, Linet M. Venous thromboembolism and cancer. The Lancet. 1998;351:1077-80.
11. Kemmerem JM, Algra A, Grobbee D. Third generation oral contraceptives and risk of venous thrombosis: meta-análisis. BMJ. 2001;323:1-9.
12. Mesa Olán A, Pérez Hernández LM, González de Varona IC, Merino Martínez E, Prado García O, González Fundora N. Profilaxis antitrombótica en cirugía protésica de cadera. Rev Cubana Ortop Traumatol. 2007 [citado 7 Jul 2012];21(2). Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0864 -215X2007000200011&lng=es&nrm=iso&tlng=es
13. Gabriel Botella F. Reflexiones sobre la enfermedad tromboembólica venosa. An Med Interna. 2003 [citado11 Dic 2011];20:447-50. Disponible en: http://scielo.isciii.es/scielo.php?pid=S0212 -71992003000900001&script=sci_arttext&tlng=en
14. Hansson P, Sörbo J, Eriksson H. Recurrent venous thromboembolism after deep vein thrombosis. Arch Intern Med. 2000;160:769-74.

Competing interests: No competing interests

23 February 2018
Moises A. Santos-Peña
Chief Organizational Quality Unit
Rocha-Hernandez Juan F., Travieso-Peña Roberto, Gonzalez-Morales Iris, Justafre-Couto Leticia, Rodriguez-Gavin Maritza
Gustavo Aldereguia University General Hospital
Ave 5 de Septiembre and 51-A street. Cienfuegos city. Cuba 55100