| Abstract | Otečena noga čest je razlog dolaska u hitni prijem, a duboka venska tromboza najvažnija je u diferencijalnoj dijagnozi. Osim DVT-a, u podlozi otečene noge može biti infekcija, limfedem, ruptura Bakerove ciste, kronična venska insuficijencija, hematom, površinska venska tromboza, itd. Pri sumnji na DVT počinje se računanjem zbroja Wellsovih kriterija. Ako on iznosi >2, postoji velika pred-testna vjerojatnost da se radi o dubokoj venskoj trombozi i slijedi UZV. Ako je pred-testna vjerojatnost niska (Wells score ≤2), potrebno je vaditi D-dimere prije ultrazvuka. D-dimeri razgradni su produkti fibrina i povišeni su u plazmi u DVT-u, ali i mnogim drugim stanjima (u trudnoći, infekcijama, DIK-u, kroničnim bolestima itd.), stoga nisu dovoljno specifični da bi potvrdili dijagnozu DVT-a. Ako D-dimeri nisu povišeni, omogućuju isključivanje duboke venske tromboze. Ultrazvučnim pregledom potvrđuje se ili isključuje dijagnoza DVT-a, a također i mnoge od diferencijalnih dijagnoza. Direktni oralni antikoagulansi (rivaroksaban, apiksaban) prvi su izbor u liječenju duboke venske tromboze u većine pacijenata. Omogućuju terapiju jednim lijekom te su pogodni za ambulantno liječenje. Druga je mogućnost početi liječenje niskomolekularnim heparinom na koje se nastavlja terapija varfarinom. Lijekovi iz skupine DOAK-a prvi su terapijski izbor i u znatnog broja onkoloških pacijenata, no u trudnih se i dalje preporučuje LMWH. U ovo istraživanje uključeno je 1388 pacijenata koji su se u periodu od 1.1.2021. do 31.21.2021. javili u OHBP KBC-a Zagreb radi otečene noge. Rezultati su pokazali da je u njih 309 (22,2%) DVT isključena na temelju Wellsovih kriterija i D-dimera. U preostalih 1079 pacijenata napravljen je UZV te je DVT bila potvrđena u 224 pacijenta (16,1%), a najčešće zahvaćene bile su femoralna i poplitealna vena. Većina pacijenata s DVT-om bila je liječena rivaroksabanom ili apiksabanom, a od ostale terapije korišteni su LMWH i martefarin. Od 224 pacijenata, samo ih je 39 (17,4%) bilo hospitalizirano, a ostatak je liječen ambulantno. Dijagnoze u pacijenata kojima je isključena DVT bile su: infekcija, površinska venska tromboza, hematom, limfedem, Bakerova cista, venska insuficijencija, artroza te nedefinirane otekline i bolovi. Stalna dostupnost UZV-a i educiranih liječnika u OHBP-u dovela je do bržeg dijagnosticiranja DVT-a, a direktni oralni antikoagulansi znatno su olakšali ambulantno liječenje. |
| Abstract (english) | Leg swelling is a common chief complaint in patients presenting to the emergency room. The most important condition to confirm or rule out is deep vein thrombosis. Some other causes of leg edema are infection, lymphedema, Baker’s cyst rupture, chronic venous insufficiency, hematoma, superficial venous thrombosis, etc. The diagnostic algorithm isn’t complex and starts with history taking and patient examinations. Clinical findings are then incorporated into the Wells score and the pre-test probability of DVT is determined. If the pre-test probability is high (score>2), ultrasound examination follows. If the score is ≤2, the D-dimer test is performed. D-dimers are fibrin degradation products, and their level can be measured in plasma. D-dimer levels are not only elevated in DVT, but in many other conditions such as pregnancy, infection, DIC, chronic illnesses, etc., and as such aren’t specific enough to diagnose DVT. Normal D-dimer levels are enough to rule out DVT. Aside from confirming or ruling out DVT, ultrasound is used to diagnose many other causes of leg swelling. Outpatient DOAC monotherapy (rivaroxaban or apixaban) is the first-line treatment used in most patients with deep vein thrombosis. Other options include LMWH and warfarin. While DOACs are a viable first-line therapy in cancer patients, LMWH is the drug of choice during pregnancy. This study included 1388 patients who presented to the Central Emergency Department of the University Hospital Center Zagreb with unilateral leg swelling between the 1st of January and the 31st of December of 2021. Results show that deep vein thrombosis was excluded using the Wells score and D-dimer testing in 309 (22,2%) patients. An ultrasound was performed on the remaining 1079 patients and, consequently, DVT was confirmed in 224 (16,1%) patients. The most common thrombosis sites were femoral and popliteal veins. Most patients were treated with rivaroxaban or apixaban; LMWH and warfarin were also used. Out of 224 patients with DVT, only 39 (17,4%) had to be admitted, while the remaining cases received outpatient treatment. Other diagnosed conditions included infections, superficial venous thrombosis, hematomas, lymphedema, Baker’s cysts, venous insufficiency, arthroses, and unclassified edema and pain. Ultrasound and doctors trained to perform it being available 24/7 in the Central Emergency Department sped up the diagnostic process of DVT and introducing DOACs as first-line treatment made outpatient therapy a lot easier. |
